Concept and Production - WHO...3 My grandfather’s worldwas hard and sad.But above all it was dark. Day rolled into night and night into day. It seemed only the singing of the birds

Editors: Dr Paul Lusamba-Dikassa Zainab AkiwumiStephen Leak

Concept and Production: Zainab Akiwumi

Layout and Design:André BamaAntoinette IlboudoKoffi AgblewonuStephen Leak

Contributors:Dr Luis Gomes SamboRegional Director, WHO Regional Office for AfricaDr Paul-Samson Lusamba-DikassaLaurent YameogoPaul EjimeGrace FobiRaogo KimaMounkaila NomaYacouba NiandouDieudonné FaoDaouda DiopHonorat ZouréPaul CaswellJoseph B. KoromaMoussa SowCarter CenterBenjamin AtwineFranck SintondjiMaimouna Diop-LySightSaversCBMIEFUFARDaniel ShunguYao AholouHailemariam Tekle AfeworkUkam OyeneMartin KollmannSimon BushAdrian HopkinsFrancisca OlamijuXavier DaneyLaurent ToéMbenda Behalal GeorgesChukwu OkoronkwoJohan WillemsBoukari NébiéVeronica OforiPascal SoubeigaSiaka Coulibaly

APOC Communication Officer:Zainab Akiwumi

For further information on the APOC Programme: Please contact theDirector of APOC: email: [email protected] or the CommunicationOfficer, Ms Zainab Akiwumi email: [email protected]

© Copyright African Programme for Onchocerciasis Control (WHO/APOC), 2011. All rights reserved.Publications of the WHO/APOC enjoy copyright protection in accordance with the Universal copyright Convention.Any use of information in this document should be accompanied by acknowledgement of WHO/APOC as the source.For rights of reproduction or translation in part or in toto, application should be made to the office of the APOCDirector, WHO/APOC, B.P. 549 Ouagadougou, Burkina Faso, [email protected]. WHO/APOC welcomes such applications.

years of APOC

credits

3

My grandfather’s world was hard and sad. But above all it was dark. Day rolled into nightand night into day. It seemed only the singing of the birds made my grandfather know that itwas morning, and the hot sun that it was day. How he told the difference during the long rainyseason I cannot imagine. His world was poor and getting poorer every day. He could no longergo to the river to fish, nor do much on the farm. His life was now one of being led around tobeg for alms. The others in the village could not help much because the blackflies had sparedno one. More than half the able-bodied men in the village were in the same plight. Mygrandmother’s sight too was rapidly failing and she could not help much either. More and morepeople were leaving the village because of the sickness there.

My mother’s world was only different in that it was much crueler. As the only girl of the familyshe had been elected to lead her father around with a stick so he could go begging for food. Herbrothers attended school. My mother talks sometimes, with tears in her eyes, of stopping bythe roadside in front of the place that served as the village school when she passed by withher father, and how she always looked longingly at the children sitting under the small shed.She often begged to be allowed to go to school on some days but the others said she wasselfish and had no pity for her father or the rest of the family. Her only hope was that shewould marry some day and escape the miserable life she was living. She was pretty enoughso getting a suitor was no problem. She married and had two children. My mother says she can hardly remember a time when her skin was not itching. To her it seemedshe had itched all her life. Over the years the constant scratching got worse and caused a lot ofbleeding that led to very ugly scars and wounds on her legs and buttocks. Her husband wasashamed of her and drove her and the children away. With nowhere to go (her parents had sincedied and her brothers did not want to know), she fled the village with her two children.

And my world? My world is lovely. Mectizan comes to town every year and I have been takingit now for the past seven years. My world is bright, gay, full of laughter and play. I go to schoolas do all the other children in my world. My mother is a distributor because she says that itwas mectizan that saved her and gave her back a life. She remarried a kind man and she hadme. She makes sure we are the first ones to get our mectizan, and she talks to all the villagepeople all the time about how important it is to take mectizan every year in order not tosuffer like she did, or like her father did.

My world is so different from my grandfather’s and I thank God for the people near andfar who have made my world possible, a world that is free of river blindness, ugly scars andwounds, stigma and rejection. My world is full of hope and dreams, and I am very happy inmy world. I am going to be a nurse when I am big so I can do more to help my community...

My grandfather’s world and mine ---two very different worldsStory of a twelve year old girl.

By Zainab Akiwumi

Zainab Akiwumi is Communication & Advocacy Officer at APOC

4

My grandfather’s world and mine --- two very different worlds.............................................................................................. 3Foreword - Regional Director.................................................................................................................................................. 5Message from the APOC Director........................................................................................................................................... 6Amazigo: celebrating the scientist with a passion for onchocerciasis control........................................................................ 7

APOC in brief ...................................................................................................................................................................................................... 8- What is APOC......................................................................................................................................................................................................... 8- Governance & organizational structure............................................................................................................................................................... 9- How APOC works – From Research to Policy to Implementation................................................................................................................ 10- Country onchocerciasis data.................................................................................................................................................................................. 11- The strength of the unique global public-private partnership that is APOC................................................................................................ 12- APOC’s unique public private partnership.......................................................................................................................................................... 13- The real APOC – seen through the eyes of a new staff member................................................................................................................... 14

How far APOC has come ................................................................................................................................................................................ 15- Some achievements.................................................................................................................................................................................................. 15- Shrinking the map - Two for the price of one: moving from control to elimination ofonchocerciasis with ivermectin treatment alone.................................................................................................................................................... 16- Putting OCP skills to work for APOC................................................................................................................................................................. 17- Onchocerciasis and gender – a new future for African communities............................................................................................................. 18

Mapping the road for CDTI ...................................................................................................................................................................... 19- REMO – determining where to treat with ivermectin....................................................................................................................................... 19- APOC has mapped the distribution of River blindness in sub-Saharan Africa............................................................................................ 20- RAPLOA – Mapping of eye worm (loiasis) for safe implementation of CDTI.......................................................................................... 21

Stories from the field ...................................................................................................................................................................................... 22- 30 years working with CBM in “oncho country”............................................................................................................................................... 22- Miracle medicine mends Nigerian tailor’s eyesight............................................................................................................................................. 23- Ugandan man helps rid his community of onchocerciasis............................................................................................................................... 24- Getting back on track with oncho control in Sierra Leone............................................................................................................................... 25- Contributing to the re-launch of CDTI activities in the Central African Republic after the war............................................................... 27- Implementing CDTI in South Sudan................................................................................................................................................................... 28- The importance of getting ivermectin to those that need it in time to make a difference!......................................................................... 29- Close view of CDTI activities in the field .......................................................................................................................................................... 30- In their own words................................................................................................................................................................................................... 31

Support for onchocerciasis control from across the ocean ........................................................................................................... 32- US citizens making a contribution to oncho control in DRC.......................................................................................................................... 32

Travelling for APOC- Ensuring training on CDTI strategy, APOC philosophy and WHO financial reporting system in countries.......................................... 33- Adventure in Taraba State, Nigeria – travelling on an empty stomach by air, by land and by river........................................................... 35- Testimonies from communities............................................................................................................................................................................. 37

Partnering with APOC ............................................................................................................................................................................... 38- Working with the poorest of the poor : CBM’s experience and commitment in the fight against river blindness.................................. 38- Sightsavers and oncho control – a long standing partnership.......................................................................................................................... 39- Pioneering community-based ivermectin distribution in Cameroon – the International Eye Foundation, USA.................................... 40- United Front Against River blindness (UFAR)................................................................................................................................................... 40- 15 years of partnership between APOC and the Mectizan® Donation Program........................................................................................ 41- The vision of the new Chair of the NGDO Coordination Group for Onchocerciasis Control............................................................... 43- Visit of Saudi Fund for Development to APOC headquarters........................................................................................................................ 44- Providing legal advice to APOC........................................................................................................................................................................... 44- Multi-disease Surveillance Centre (MDSC)......................................................................................................................................................... 45- Perspective................................................................................................................................................................................................................ 46

Men and woman at the helm of oncho success .............................................................................................................................. 47- Past and present OCP and APOC Directors...................................................................................................................................................... 47- Pioneers of River blindness control in Africa..................................................................................................................................................... 48

Spotlight on APOC countries....................................................................................................................................................................... 49●Nigeria- Onchocerciasis Programme Milestones............................................................................................................... 49●Central African Republic - CBM’s experience in Central African Republic.................................................................. 50●Nigeria - Cultural.................................................................................................................................................................... 51●RCA - Cultural........................................................................................................................................................................ 53

Contents

5

Foreword

Regional Director

Just a little over 15 years ago, in December 1995, the African Programme for Onchocerciasis

Control (APOC) was launched to control the disease in 19 endemic countries outside the

OCP zone. When the programme started operations in 1996 the challenges were many but

APOC has always known how to meet these challenges through research and the

development of effective tools. Today APOC is a public health success story that is providing

relief to millions of African people in the poorest and remotest areas where there are no

health services. This success has only been possible because of the unique public-private

partnership and the steadfast support that APOC has enjoyed since its inception.

The results on the ground over the past 15 years have shown clearly that APOC works,

and that its strategy, Community-Directed Treatment with Ivermectin (CDTI) is effective in

improving people’s health particularly in the most remote areas. The benefits for affected

populations have been many, and today APOC is even moving into a new dimension now

that the principle of the feasibility of elimination of the disease with ivermectin treatment

alone has been established.

The stories and articles in this magazine, sometimes about personal experiences, sometimes

about the tool developed and measures taken to meet a particular challenge are all

testimonies of the dedication and passion of the people and organizations involved in

onchocerciasis control in Africa. They demonstrate what can be achieved when people join

forces and strive together for a common goal.

I thank all our dedicated partners who have been supporting APOC these past fifteen years,

and look forward to continued collaboration to rid Africa of onchocerciasis.

Dr Luis Gomes SamboRegional Director

WHO - Regional Office for Africa

6

The last fifteen years have been a period of intense investment and excellent results forAPOC. Much has been learned on onchocerciasis control interventions, including theuse of medicines and their side effects in the situation of co-morbidity with loiasis.Above all, Community-Directed Treatment with Ivermectin (CDTI) has been establishedas one of the most effective public health interventions, reaching more than 68 millionpersons in 2009. Its economic rate of return is estimated at 17%. In addition, over 38million persons benefited from multiple health interventions using CDTI as an entry point. During these past 15 years, most of the efforts have been geared towards the controlof onchocerciasis as a major public health problem affecting millions of persons amongthe poorest. Now, scientific evidence has demonstrated the feasibility of onchocerciasiselimination, thus opening a window of hope for the future. At the same time, severalquestions, many of them still unanswered, are being raised. Several issues still needto be addressed. Communities, countries, experts, and development partners all wishto see light and a clear path to the future.

There is no doubt that the communities that have benefited from the global effort totackle the scourge will request to sustain this effort as long as it takes, and to definitely

get rid of onchocerciasis. Most probably, communities will continue to participate willingly in this effort and to demonstrateownership.

Experts and donors alike are pondering on the duration of community mass treatment with Ivermectin. For how long should wesustain control interventions? Scientists would like to be assured that alternative medicines for mass treatment are discovered.They wish to access non invasive diagnostic tools in place of the skin snip for epidemiological evaluations; and innovativetrapping systems to replace human blackfly capturers.

Programme officers are concerned about project performance, including geographic and therapeutic coverage. They wish to bereassured about the sustainability of interventions since onchocerciasis control and elimination activities need to be carried outover several years. At the same time, questions are being asked about APOC: what will happen beyond the year 2015 whichis the end of the current mandate of the Programme? Would governments and affected communities be ready to take overand ensure that onchocerciasis is eliminated in the long run?

The fifteen year milestone is a good time for reflection. It is certainly a time for hope. It is mostly a time for importantcommitments:

- Commitment to protecting the gains made through sustained partnership;- Commitment to sustaining, as long as necessary, the implementation of the Community-Directed Treatment with

Ivermectin strategy;- Commitment to applying the experience gained for addressing other relevant public health problems.

It is comforting to know that, during its 16th session held in Abuja, the Joint Action Forum (JAF) requested the Committee ofSponsoring Agencies (CSA) and APOC Secretariat to set-up Advisory Groups that would review available information and makeproposals on the three themes below:

- Elimination of onchocerciasis and interruption of transmission- Co-implementation- The future of APOC

Under the first theme the feasibility of eliminating onchocerciasis and its transmission, so that the disease will never againthreaten communities must be addressed, as well as the necessary strategies and the timeframe for this to happen. Reflectionson the second theme should result in guidance on other public health interventions that may be implemented jointly throughthe CDTI strategy with effective country ownership. Finally, under the third theme, recommendations should be made on waysand means to ensure that the gains made through the APOC global public-private partnership are preserved and that thispartnership is sustained as long as needed, both for River blindness elimination, and support to countries for other public healthinterventions.

It is indeed a challenge to deliver the expected outputs to the JAF by December 2011. The CSA Advisory Group, with supportfrom APOC Management, has already started working relentlessly on the assignment. It is hoped that this work will yieldenough information to allow stakeholders of onchocerciasis control in Africa to make the most appropriate decisions for thefuture.

Dr Paul-Samson Lusamba-DikassaDirector, APOC

Onchocerciasis Control and Elimination in Africa: Future outlook

Message from the APOC Director

7

Amazigo: Celebrating the Scientist wi th a Passion for Onchocerciasis Control

By Paul Ejime

After several decades ofillustrious serviceincluding the last 15 atthe World HealthOrganization AfricanProgramme forOnchocerciasis (Riverblindness) Control(WHO/APOC), it is time

for Dr Uche Amazigo, auniversity teacher, health

management expert, mother, researcher and humanist tocount her blessings having made an impact in the world ofonchocerciasis control.

Since her retirement on 31st March 2011 as Director of theWHO African Programme for River blindness Control, theformer senior lecturer and parasitologist with specializationin tropical diseases and public health has been receivingpraises for her selfless commitment to serving the needs ofthe poorest of the poor in Africa.

To cap her distinguished service, the Government ofBurkina Faso recently bestowed on Amazigo thedistinguished Medal of “Knight of the National Order ofBurkina Faso,” a rare achievement for a non-native. WHORegional Director for Africa, Dr Luis Gomes Sambo, onbehalf of the WHO Director General Margaret Chan, alsocommended Amazigo for “her excellent work” as Directorof APOC.

As WHO and partners sought scientific and practicalsolutions to the River blindness scourge, Amazigo, back inher native country Nigeria had developed more than anacademic interest in the disease. In the early 1990s she wasa teacher of parasitology at the University of Nigeria,Nsukka, but Amazigo was not content with just impartingknowledge to young medical professionals. Shecomplemented her classroom teaching with research andfield work, and it was during a field visit to an antenatal clinicin Etteh village, Enugu State in South-eastern Nigeria thatAmazigo’s career world changed.

During a chance meeting at this clinic with a womanafflicted with River blindness, Dr Amazigo resolved to makea difference. She not only undertook to pay for thetreatment of the afflicted woman who had been abandonedby her husband because of the stigma of itching anddiscolouration of her skin by onchocerciasis, but alsodecided, with funding by the WHO, to research into thesocial impact of the disease.

Following her ground-breaking research, Amazigo joinedthe APOC programme in Burkina Faso in 1995 andcontributed to the translation of research findings intodeliverable products and services. In 2005, she wasappointed the first female Director to lead the multi-million-dollar multi-stakeholder regional WHO/APOC programme.

Since inception, the programme has recorded an 86%reduction in severe unrelenting itching, 39% reduction ininfection prevalence of the disease, prevention of more than500,000 cases of blindness and an estimated Economic Rateof Return of 17% on invested funds. Annual treatment withivermectin in APOC countries has increased from 1.5million in 1997, to 68.4 million in 2009, nearing theprojected target of 90 million by 2015.

Dr Amazigo insists that the internationally-acknowledgedachievements of the WHO/APOC programme were madepossible through the combined effort of all partners andstakeholders. “The achievements by WHO/APOC wouldnot have been possible without the unwavering commitmentand support of donors, NGDOs, ministries of health,dedicated scientists and strong community involvement,”she stressed.

Amazigo has played her part and the greatest tribute to heruntiring efforts is the continuation of the battle until Africais freed, not only of River blindness but of all neglectedtropical diseases so that the continent can realize its fulldevelopment potential.

Mr Paul Ejime is a Communication/Media Consultant

Amazigo after her decoration withthe Medal of Knight of the

National Order of Burkina Fasoin Ouagadougou

15 years of APOC

African Programme for Onchocerciasis Control8

APOC... in brief What is APOC ?

APOC is a unique global public-private partnershiplaunched in December 1995 with the goal of eliminatingonchocerciasis as a disease of public health and socio-economic importance throughout Africa.

Building on the success of the Onchocerciasis ControlProgramme (OCP), APOC’s objective was to set upeffective control programmes in the endemic Africancountries outside the OCP zone.

APOC’s Core Operating Principles

- Community ownership & empowerment- Sustainability- Evidence-based decision-making- Partnership- External evaluation

The partnership = The true strength of APOC =partners with a shared vision, working jointly togethertowards a common goal

- 20 Donor countries and organizations who are

committed and have been providing financial supportfor the programme since it was launched- 15 Non - Governmental Development Organizations(NGDOs) equally committed and provide financial andtechnical support at national and community levels - 19 Participating African countries: Angola,Burundi, Cameroon, Central African Republic, Chad,Congo, Democratic Republic of Congo, Ethiopia,Equatorial Guinea, Gabon, Kenya, Liberia, Malawi,Mozambique, Nigeria, Rwanda, Sudan, Tanzania, andUganda - Merck & Co. Inc. – donates Mectizan® to all whoneed it for as long as needed- Research organizations and institutions- 146,000 endemic communities

Executing agency – WHO- responsible for the day-day running of operations implementing theprogramme

Fiscal Agency: World Bank, responsible for raisingfunds and managing the APOC Trust Fund.

15 years of APOC

African Programme for Onchocerciasis Control 9

APOC... in brief

Onchocerciasis, or 'river blindness’ as it is more commonly known, is a parasitic disease caused by the filarial worm Onchocercavolvulus and is a major cause of preventable blindness worldwide. It is transmitted through the bite of infected Simulium blackflies,that breed in fast-flowing streams and rivers. It can cause intense itching, disfiguring dermatitis, eye lesions and over time blindness.It is endemic in 30 countries in sub-Saharan Africa mainly in rural communities. In most of these countries onchocerciasis constitutesa public health problem and a serious obstacle to socio-economic development. Onchocerciasis is also prevalent in a few countriesin Latin America and in Yemen. 96% of the 125 million people world-wide at risk are in Africa and 99% of the 18 million people infected with the disease live inAfrica. About half a million people are blind or visually impaired due to the disease. Onchocerciasis also causes ugly skin diseasewith depigmentation and severe unrelenting itching. People with the disease often have low self esteem, experience social isolation,and worry that they will never marry. Children are distracted in school due to constant itching.Before large-scale coordinated efforts to control the disease the risk of onchocercal blindness was very high along the riverinebreeding sites of the blackfly vector in West Africa. Blindness affected up to 50% of adults in some areas, and people abandonedthe fertile river valleys for fear of contracting the disease. Poverty and famine increased. In the 1970’s, economic losses wereestimated at US$30 million, and onchocerciasis became a major obstacle to socioeconomic development.

Treatment and control of onchocerciasisLarge-scale efforts to control the disease started in 1974 with the launching of the Onchocerciasis Control Progamme (OCP) toeliminate the disease first in seven, and eventually in eleven West African countries. OCP’s strategy was vector control to kill thelarvae of the blackfly vector through aerial spraying of larvicides on fast flowing rivers and streams, and hand spraying of breedinggrounds. Spraying continued for more than 14 years, even through civil and regional conflicts, to break the life-cycle of the parasite.Vector control was later combined with treatment of eligible populations with ivermectin (Mectizan) when the drug was discoveredand made available to the people in endemic communities. The African Programme for Onchocerciasis Control (APOC) was set up in 1995 to eliminate onchocerciasis as a disease of publichealth importance in Africa in the other endemic countries outside the OCP zone. APOC’s strategy is CDTI – Community-DirectedTreatment with Ivermectin. CDTI relies on active community participation to distribute ivermectin treatment to people who need it.This successful strategy is now being extended to include delivery of other health interventions, such as insecticide-treated nets formalaria prevention, and vitamin A distribution.

ONCHOCERCIASIS - THE DISEASE

Governance and organizational structure

15 years of APOC


APOC... in brief How APOC works

Research

APOC’s operations and activities have always been guidedand based on research and evidence. Research results are usedto determine all policies for control activities. APOC’s mainresearch partner is UNDP/World Bank, WHO SpecialProgramme for Research & Training (TDR). APOC alsoworks with universities and other research institutions.

One of the challenges facing APOC at the beginning was todetermine the delivery method most capable of eliminatingoncho as a public health problem? A multi-country studycarried out by TDR concluded that distributors selected bythe communities with support from their communities areable to carry out the distribution of Mectizan® tabletsefficiently, give the correct dosage, exclude those who shouldnot be treated and report on the distribution.

Policy

All research results are discussed at the Committee ofSponsoring Agencies (CSA) which makes recommendationsto the Joint Action Forum (JAF) for approval beforeimplementation. In 1997 The JAF approved and adopted theCommunity-Directed Treatment with Ivermectin (CDTI) asthe programme’s main drug delivery strategy.

Implementation

The APOC Strategy - CDTI

The Community-Directed Treatment with Ivermectin (CDTI)adopted by APOC in 1997 relies on active participation and

promotes community ownership and empowerment ofcommunities. Communities take responsibility for ivermectindistribution and decide how, when and by whom theivermectin treatment should be administered. CDTI hasproved very successful and in the rural areas where healthservices are weak or sometimes even non-existent, it iscontributing significantly to reducing the onchocerciasisburden in Africa. Increasingly this strategy is now being usedby communities to bring other health interventions to thepeople who need them most.

The Mectizan Donation Programme set up by Merckadministers the procurement and delivery of the drugs tocountries that need and request it. The MDP works closelywith ministers of health and other partners

Where APOC works

Out of the 19 countries REMO results showed that four hadmainly hypo-endemic areas with small pockets of meso-endemic communities and so would not require mass drugadministration. Clinic-based treatment was thereforerecommended.

APOC therefore works in the remaining 15 countries:Angola, Burundi, Cameroon, Central African Republic, Chad,Congo, Democratic Republic of Congo, Ethiopia, EquatorialGuinea, Liberia, Malawi, Nigeria, Sudan, Tanzania, andUganda and four ex-OCP countries: Cote d’Ivoire, Ghana,Guinea Bissau and Sierra Leone.

From Research to Policy to Implementation

15 years of APOC


APOC... in brief Country onchocerciasis data

15 years of APOC


APOC... in brief

Onchocerciasis is not only the world’s second largest causeof infectious blindness but also causes severe itching,inflammation, swelling and skin disfigurement that haveserious socio-cultural implications. Fear of the disease oftencaused people to abandon fertile lands which in turn led toan increase in poverty and famine and constituted a majorobstacle to socioeconomic development.

Efforts to control river blindness in sub-Saharan Africastarted several decades ago. In the 1950s and 1960s attemptswere made to control the disease on a small scale in thehardest-hit areas (Volta River basin, Benin, Ghana, Coted’Ivoire, Mali, Niger, Togo, Burkina Faso) but suchuncoordinated national control efforts did not produce anylasting results because of the ability of the blackfly thattransmits the disease to cover long distances and crossborders. Re-invasion was a very common occurrence andthis made uncoordinated national control efforts ineffective.

At an international conference in Tunisia in 1968 participantsconcluded that the disease could be controlled if addressedon a sufficiently large scale. Scientists from WHO and otherexperts contributed to the preparation of a regional controlplan. Several donors expressed interest. Thus a partnershipwas born, and the Onchocerciasis Control Programme(OCP) was formally launched in 1974 to eliminate oncho asa public health problem and mitigate the negative impact onthe social and economic development of affected areas.

The OCP initially included seven countries, WHO, the WorldBank, the UN Development Programme and the UN Foodand Agriculture Organization. Participation eventuallyincreased to eleven countries in West Africa with more than25 donors, some non-governmental organizations (NGOs)and numerous rural community groups.

The sustained commitment of bilateral and multilateraldonors, NGDOs, national governments and other partnersinvolved in the OCP made this programme a major andimpressive public health success story that continues tilltoday. Transmission of the disease has been virtually haltedin almost all the targeted West African countries, 600,000cases of blindness were prevented, and more than 20 millionchildren born in the OCP area are now free from the risk ofcontracting river blindness. About 25 million hectares ofarable land is safe for re-settlement.

It was indeed this success and the same commitment andunwavering support of the donors and NGDOs and otherpartners that led to the creation of the African Programmefor Onchocerciasis Control (APOC) in 1995 to control riverblindness in the non OCP endemic countries in Africa.

The historic pledge by Merck to donate Mectizan “to anyonewho needed it, for as long as it was needed” marked the startof the world’s longest ongoing medical donationprogramme, and one of the largest public-privatepartnerships ever created. APOC is a unique globalpartnership which brings together 19 participating countrieswith the active involvement of the Ministries of Health andtheir affected communities, several international and localNGDOs, the scientific community, the private sector (Merck& Co., Inc.), several multilateral and bilateral donors, UNagencies and more than 120,000 rural African communities.

The success and strength of this unique global private-publicpartnership has been demonstrated countless times in thepast 15 years. Starting with only four projects in 1996, APOChas scaled up operations and today has achieved communitydelivery of over 1.3 billion tablets of ivermectin,

administered 447 million doses of treatment and hasCDTI projects operating in 91% of the APOC areaprotecting 96% of the 94 million people targeted with anoverall treatment coverage of 89%. Such significantachievements could not have been possible without thesteadfast and generous support of the APOC partnership.

This special public-private partnership has worked so wellthat it now faces a new challenge: the shift from controlto elimination. Given the successes of the past there is nodoubt that the partnership can meet this new challengeand rid Africa of onchocerciasis.

Dr Grace Fobiis Community Ownership and Partnership Officer at APOC

"If you want to go fast, go by yourself, if you want to go far, go with others” (African proverb)

By Dr Grace Fobi

NGDO Group for Onchocerciasis Control WHO Geneva September 2006.

The strength of the unique globalpublic-private partnership that is APOC

15 years of APOC


APOC... in brief APOC’s unique public private partnership

• Angola• Burundi• Cameroon• Central African Republic• Chad• Congo•Democratic Republic of the Congo• Equatorial Guinea• Ethiopia• Gabon• Kenya• Liberia• Malawi

• Mozambique• Nigeria• Rwanda• Sudan• Uganda• United Republic of Tanzania

ExOCP• Cote d’Ivoire• Ghana• Guinea Bissau• Sierra Leone

UNICEF /UNDP/WorldBank/WHOSpecial Programme forResearch and Trainingin Tropical Diseases(TDR)

Full Members:• Charitable Society for Social Welfare• ChristoffelBlindenmission• Helen Keller International• IMA World Health• International Eye Foundation• Light for the World• Lions Club International Foundation• Mectizan Donation Program• Mission to Save the Helpless• Organisation pour la Prévention

de la Cécité

• Schistosomiasis Control Initiative• Sight Savers • The Carter Center• United Front Against River

Blindness• US Fund for UNICEF

Associate Members:

CNTD IAPB Merck

• African Development Bank• Belgium• Calouste Gulbenkian Foundation• Canada• France• Germany• Kuwait Fund• Luxembourg• Merck & Co., Inc.• T he Netherlands• Norway

• OPEC Fund• Poland• Saudi Arabia• Slovenia• UNDP• United Kingdom of Great Britain

and Northern Ireland• United States of America• World Bank• World Health Organization

APOC Participating Countries

NGDO Partners

Research Partner

MERCK & Co., Inc.

Private Sector

DONORS:Contributing

Partners

146,000 Endemic Communities

15 years of APOC


APOC... in brief The real APOC

I must have driven past the APOC building on Avenue NaabaZombré in Ouagadougou, Burkina Faso countless timesbefore April 2010. I never really paid much attention to thebuilding as there was nothing much to see except thisnondescript wall with a small part of a building visible fromthe outside. There is a big sign on the pavement alright thatreads, “APOC / MDSC Headquarters”, but it did not tell memuch. I doubt many people paid attention except if theyhad business there.

Last year for the first time I entered the gates of this structureto take a recruitment test. You can imagine how surprised Iwas to see several buildings in the large compound. In fact Ifelt quite intimidated and my steps did indeed falter. Thethought in my mind was: this modest looking building fromthe outside has a lot more to it. I now felt even morehonoured to have been short-listed to take a test for theposition of translator.

Walking down the corridors to the room where the test wasbeing held and counting so many doors I began to imaginethe importance of the work being done within and knew withall my heart that I wanted to be part of this organization.

My prayers were answered and I was recruited. I joined theAPOC Programme in April and it was during the briefingsessions I had with the different units of APOC that firstweek that I began to have some idea of the scope andmagnitude of the work and operations of the Organization.This building housed the management of a network ofpeople from all over the world managing and coordinatingoperations that bring vital health intervention to tens ofmillions of people in Africa. The nondescript building andwalls I used to see from the road outside now took on a bigmeaning and became its actual size – that of a globalprogramme.

It was fascinating learning about the work of APOC andgetting to know how it all fitted together, from the work doneat the headquarters in Ouagadougou, to the contribution ofdonors and NGDO partners worldwide to the affectedcommunities who were the final beneficiaries of theprogramme. I thought I had seen and learnt the full scopeof the programme during the first seven months atheadquarters but it was when I attended the 16th session ofthe Joint Action Forum (JAF) in Abuja in December 2010that I realized how truly impressive this Organization was.The JAF is the governing board of APOC and bringstogether, once a year, the finest people from different walksof life but all with one common goal – to control andeliminate onchocerciasis in Africa.

It was heartwarming to feel the commitment of bilateral andmultilateral donors and NGDOs from the four corners ofthe world, dedicated international scientists, representativesof pharmaceutical companies from the West, Ministers ofHealth from APOC and ex OCP countries, coordinators ofNational Onchocerciasis Control Programmes who hadcome to this meeting with one purpose in mind - to reviewand guide APOC operations to ensure that the job ofcontrolling and eliminating onchocerciasis will be done. Whata remarkable partnership!!

I thought of my colleagues who had stayed behind inOuagadougou and wished they were in Abuja to witness theforum that they, in the day to day conduct of their differenttasks, had also contributed to. Indeed this Forum was madepossible because of what goes on in the offices in thatseemingly nondescript building in a quiet street inOuagadougou.

Dr Raogo Kima is translator at APOC

By Raogo Kima

15 years of APOC


How far APOC has come Some achievements...

Since 1997 APOC has achieved the following:

� Almost 70 million people treated with ivermectin in 2009,reaching 75% of the target population (90 million). � A cumulative total of 447 million ivermectin treatmentsadministered� CDTI projects operating in 96% of target countriesprotecting 94 million people�91% of APOC area covered geographically�89% therapeutic coverage �146,000 communities engaged in CDTI�A cumulative total of 1.3 billion ivermectin tablets deliveredby communities � Ivermectin treatment scaled up in 5 post-conflict countries�34 medical and nursing schools to incorporate the teachingof the CDI strategy in their curricula (9 Eastern andSouthern and 11 West and Central African countries - 20countries across Africa).

From 1996 to 2009 APOC has trained people in thefollowing areas:

The impact of APOC activities is also remarkable:

� 120 million people at risk protected from contracting thedisease� 86% reduction of severe itching� More than 500,000 cases of blindness prevented� An average of 375 African professionals trained intechnical and financial management skills annually� Economic rate of return estimated at 17% on fundsinvested� Chad, Cameroon, Nigeria and Uganda showing evidenceof being able to stop ivermectin treatment as transmissionof infection has been interrupted.

When APOC started operations in 1996 it was obliged to start small because, though its mandate to eliminateonchocerciasis as a disease of public health importance and as an important constraint to socio-economicdevelopment throughout Africa was clear, there were many unknowns and challenges. Some of them quitedaunting:

41.9 million people were estimated to be infected with the disease, 29.7 million were suffering with persistent itchingand skin lesions, approximately 400,000 people were blind and almost a million had impaired vision. It wasimperative to act fast and effectively.

In 1996 APOC could only launch four CDTI projects in countries (Malawi and Uganda) that were already carryingout community based treatment. Today, however, thanks to its unique public-private partnership and itsphilosophy of basing the implementation of its operations on research results and evidence, APOC can boast ofmany ground-breaking successes.

Disease mapping 1,500

CDTI (MoH & NGDO staff) 80,000

Trainers for SAE management 105

Data management & analysis 900+

M&E of projects 1,100

Entomology 135

Operational research 23

Epidemiology +100

MPH (Masters in Public Health) 15

Financial management procedures 350

Resource mobilization 151

15 years of APOC


How far APOC has come Shrinking the map

Two for the price of one: moving from control to eliminationof onchocerciasis with ivermectin treatment alone

Fifteen years ago when APOC was established in 1995 itsmandate was to eliminate onchocerciasis as a disease ofpublic health and socio-economic importance throughoutAfrica.

With the start of operations in 1997 and launch of itsCommunity Directed Treatment with Ivermectin (CDTI)strategy, APOC’s aim was to encourage communities to ownthe programme and empower them to direct and implementthe distribution of ivermectin themselves. The best thatcould be hoped for was that APOC - building upon thesuccess of the Onchocerciasis Control Programme in WestAfrica (OCP), which was on the verge of eliminating thedisease from 11 West African countries, and the pledge ofMerck and Co., inc. to provide Mectizan free of charge toall that needed it for as long as needed - would establishsustainable control in the remaining 19 countries in Africa,where the disease is still a public health problem.

Mass treatment with ivermectin has indeed been successfulin controlling river blindness as a public health problem, butit was not known whether it could interrupt transmission ofthe disease and eliminate the parasite so that treatment could

be stopped. In fact manyscientists doubted that

onchocerciasis elimination was feasible in Africa althoughthis had been achieved in some areas of the Americas.

The doubts have now been removed. The results of thestudy conducted in three hyper-endemic foci in Senegal andMali where treatment with ivermectin alone has been goingon for 15 to 17 years (Diawara et al, PLoS Negl Trop Dis2009; 3(7): e497) have shown that onchocerciasis eliminationis feasible with ivermectin treatment in some foci in Africa.

This is an exciting time for APOC, its donors and partnersbecause what started out as a programme to control riverblindness has received an unexpected windfall and with theproof of principle of elimination of onchocerciasis withivermectin alone now clearly established it’s like getting twofor the price of one. Epidemiological evaluation results(2008-2010) have shown that elimination of onchocerciasisinfection is feasible in Nigeria, Cameroon, Chad, Ugandaand Tanzania. APOC has been given an additional mandate:to determine when and where ivermectin treatment can bestopped, and provide guidance to countries preparing tostop ivermectin treatment. APOC is well on the way toshrinking the oncho map of Africa

Dr Moukaila Noma is the Chief of the Vector Elimination Unit

In WestAfrica, control of the disease under theOnchocerciasis Control Programme (OCP) wasbased mainly on vector control with aerialspraying of the breeding sites along fast flowingrivers with environmentally safe insecticides tokill the larva of theblackflies that transmitthe disease. For APOCcountries however, aerialspraying was notconsidered a viableoption because it wasnot feasible or cost-effective except for afew small and isolatedfoci. These foci, twoin Uganda, one in Equatorial Guinea and one inTanzania were identified at the start of theprogramme because they were isolated and ranno risk of being reinvaded by blackflies fromneighbouring zones. APOC has successfullycontrolled the Onchocerciasis vector from theItwara foci in Uganda through ground larviciding,and on the island of Bioko in Equatorial Guineawith a combination of ground larviciding andaerial spraying.

Vector elimination

By Moukaila Noma

The island of Bioko is part of Equatorial Guinea and is located in the Gulf of Guinea,off the coast of Cameroon and Gabon. It is the only island in the world to beonchocerciasis endemic. Vector controlLarge scale aerial and ground larviciding started in 2003. Environmental surveysundertaken before and after treatments, revealed that the number of fish speciesremained constant, quantity of shrimps undisturbed and not reduced. The density ofmacro-invertebrate in 2003 is comparable to that observed in 1999 (feasibility of phase).In 2005 aerial spraying was combined with ground larviciding. Since May 2005, thevector, Simulium yahense was eliminated from Bioko Island. Reinforcement ofcommunity-directed treatment with ivermectin is expected to lead to rapid eliminationof onchocerciasis.

Bioko Island, Equatorial Guinea

15 years of APOC

African Programme for Onchocerciasis Control

How far APOC has come Shrinking the map

17

Putting OCP skills to work for APOC

I joined the vector control unit (VCU) of the OCP in August1999 as technical assistant and was responsible for thefollowing tasks:- Training nationals in technical entomological evaluations(capture, morphological identification, dissection of femaleblackflies, prospecting of larval breeding sites

- Training nationals in ground spraying- Sensitization of political, administrative and traditional authorities,

the media and the people- Data entry of capture and dissection of female blackflies- Extraction and processing of data for the VCU unit- Development of entomological maps for weekly briefing These were all very dynamic and enriching activities that Icarried out with great passion, until the closure of the OCPin 2002. Professionally speaking it was a very fulfilling andexciting time of my life. In the area of sensitization I workedvery closely with the people on the ground on variousthemes such as biology and nuisance factor of the Simulium

blackflies, vector control methods, insecticides,environmental pollution, ivermectin distribution andmotivation of community distributors. The work was quitevaried and included fieldwork, weekly radio briefings,production of summary reports, training workshops andbrain storming meetings to exchange ideas.

I joined APOC in January 2003 working in theEpidemiology and Vector elimination unit, but with othertasks, albeit contributing in my own small way to theachievements of the objectives of this new programme. Itwas with great joy and excitement that I welcomed theopportunity, a few years later, to put to use my experiencefrom OCP for the benefit of APOC.In 2005, under the vector elimination project for Tukuyu in

Tanzania, I was part of a team carrying out groundlarviciding using environmentally safe insecticides,prospecting for Simulium blackfly breeding sites anddissection of female blackflies. During these activities wewere called upon to respond to the questions asked by thepeople and reassure them about the safety of the different

products poured into the rivers, and their impact on theenvironment, the fish, the waters, and of course on thepeople living near the rivers.

After the successful aerial larviciding campaigns in Bioko,Equatorial Guinea in 2005 an entomological surveillanceprogramme was set up, and in 2006 I participated in theimplementation of this programme and led theentomological surveillance missions. These includedcollecting capture data, dissection of female blackflies andprospecting of possible breeding sites of Simuliumdamnosum, the vector of the disease. In Bioko, incollaboration with the oncho team I also sensitized thepeople on the need for total involvement of the localpopulation in entomological surveillance in order to obtainquality data, which is so vital for the onchocerciasis vectorelimination certification process. We also had to sensitizethe people on the need for communities to take up fullownership of CDTI to ensure that their villages are rid ofriver blindness.

For me, the success of the OCP and APOCprogrammes is a combination of all these experiences,both individual and collective, put together to make awhole.

Mr Dieudonné Fao is data entry and data management assistant

By Dieudonné Fao

Preparing insecticide in a sprayer - Tukuyu

Prospection of breeding site – Bioko

15 years of APOC


How far APOC has come Onchocerciasis and gender

Gender issues are now emphasized in all of the programme’splans and activities. This is all the more relevant in thatcommunity ownership cannot be realized without the full andconscious involvement of women and young people - womenbeing the most important here. Especially since in almost allAfrican countries women make up more than 50% of thepopulation. And as regards onchocerciasis, more than 61%of people treated in meso and hyper-endemic areas infourteen out of the fifteen APOC countries carrying outCDTI are women.

It is therefore urgent and most relevant for women to be atthe centre of the management of the disease at communitylevel. Indeed, ownership without empowering womenmarginalizes the majority of the population.

Working to ensure that women and young people (girls aswell as boys) take up the responsibilities due to them, by theirsheer numbers and by the extent of their presence inwomen’s groups and organizations, is the new leitmotiv forAPOC. To ensure women take up their rightful place withinthe community and in community health managementinstitutions, become pillars of CDTI and work towardscommunity ownership and community self-empowerment isnow a major objective for APOC and all its partners.

APOC is fully aware that neither sustainable oncho controlnor elimination can be achieved without the full andconscious participation of young people and women in themanagement of onchocerciasis and all other communityhealth issues.

It is for this reason that APOC has developed a strategy forgender mainstreaming in integrated participatory communityhealth management as part of the CDTI strategy. Thelaunching of the implementation of the strategy has startedto produce some promising results that must be entrenchedand extended to cover all regions of all 19 APOC countries,

as well as the ex OCP countries that may be consideringelimination.

In the Central African Republic, in all five prefectures whereoncho control activities are carried out, action plans forgender mainstreaming and promotion of female leadershipfor equitable community leadership have been prepared.These plans will soon be implemented in the areas andcommunities concerned.

Male adults and youths, doctors and head nurses have decidedto associate women in all activities as CDDs by setting upmixed teams to distribute ivermectin and carry out surveys.

One CDD and some female community leaders have starteda door-to-door campaign to sensitize the women, theirhusbands, children and parents to encourage them to be fullyinvolved, with the blessing of the entire community. OneCDD started a theatrical group to sensitize the women andmen in the villages about the need for women to participateactively in the fight against oncho and other NTDs atcommunity level.

This is true also of Cameroon where a pool of genderresource persons striving for the promotion of femaleleadership has been constituted. It is hoped that such groupswill become firmly established and will be extended to thewhole of Central Africa. The same movement is also ongoing in Malawi, Tanzania, Nigeria Equatorial Guinea,Burundi, Uganda and will hopefully start in Chad this year.

APOC is fully committed to ensuring that women play amajor role in CDTI activities at community and national level.The CDI strategy also provides them with a platform formore involvement in the control of other NTDs.

Dr Daouda Diop is gender specialist /APOC

A new future for African communities...By Daouda Diop

Group of female CDDs

15 years of APOC


Mapping the road for CDTI

19

When APOC was launched in 1995 one of the majorchallenges it faced was to determine where to carry outivermectin treatment. The data on onchocerciasis endemicityin APOC countries were very inadequate. There were somehistorical data based on studies carried out in foci inCameroon, Nigeria and Burundi but clearly more evidence-based data were needed since the APOC objective was totarget the most highly endemic communities.

On the basis of available data the WHO Expert Committeeon onchocerciasis had estimated the number of peopleinfected in the geographical area of the Programme at13,702,000. It was important to update the prevalence datain order to identify the populations infected or at high-riskof being infected by the disease. Given the wide extent ofthe Programme, a rapid and reliable method for evaluatingthe prevalence of onchocerciasis was required to determinethe areas where mass administration of ivermectin is apriority.

A research study conducted by WHO/TDR made it possibleto develop a rapid and non-invasive method called RapidEpidemiological Mapping of onchocerciasis (REMO) thatcould be used to identify and map communities at high riskfrom onchocerciasis quickly and cheaply. The method usedto assess oncho prevalence was the invasive skin snip frownedupon by communities and the international communitybecause of the risks of HIV/AIDS. REMO was therefore awelcome alternative.

Mapping the road for CDTI was indeed a majorchallenge:

The first step was to consult existing maps to identify majorwaterways and the primary (closest to the river) andsecondary villages along them. Next, a sample of 2-4% ofvillages in the area is assessed for the presence ofonchocerciasis by feeling for sub-cutaneous nodules in 30-50adults in each village. The adults should be at least 20 yearsold and should have been living in the village for at least tenyears. The data collected are integrated into a GeographicalInformation System (GIS).

Based on the results of the REMO exercise three types ofoperational area are identified:

1. Definite-CDTI area means that onchocerciasis is highlyendemic and constitutes a public health problem and massivermectin treatment is a priority

2. No-CDTI area has low or no transmission of O. volvulusand oncho is not considered a public health problem Clinicbased ivermectin treatment may be provided where there istransmission 3. Possible-CDTI area. Here the epidemiological pattern isnot clear and may require refinement of the map throughfurther surveys.

REMO results show that in four APOC participatingcountries, Gabon, Kenya, Mozambique and Rwanda thelevels of oncho endemicity were below the threshold forCDTI. Clinic–based ivermectin treatment was recommendedwhere necessary.

REMO has helped countries to identify where onchocerciasisis a public health problem, to determine where a CDTIproject should be established, the number of people at riskof contracting the disease, and who should benefit fromivermectin mass treatment. With REMO data it is possibleto estimate the quantity of ivermectin tablets required tocarry out a cycle of treatment given an average of threetablets per person per treatment cycle. And for APOCManagement, knowing the number of the population at riskin a project is useful for financial estimation of its cost.

REMO results have been vital for defining the roadmap for CDTI implementation

One of the outcomes of conducting REMO surveys is theproduction for each country of 2 types of map: anepidemiological map showing the geographical distributionof the disease and an operational map (“CDTI priority map”)where a red colour is used to show the geographical areaswhere communities should conduct mass distribution ofivermectin to control onchocerciasis as a disease of publichealth importance. The epidemiological map provides usefulinformation to the scientific community and the CDTI mapis used by the Ministries of Health and their partners as anadvocacy document to mobilize financial resources and createa broad partnership to fight river blindness

To date, the mapping of the distribution ofonchocerciasis is completed in Africa with more than13,000 villages visited and over 470 000 people examinedin the 19 African countries.

Mr Honorat Zouré is Biostatistics Information and MappingManager at APOC

By Honorat ZOURE

REMO - determining whereto treat with ivermectin

15 years of APOC



APOC has mapped the distribution of River blindness in sub-Saharan Africa

(surveyed >13,000 villages in 19 countries)

120 million people at high risk in remote areas in Africa

15 years of APOC



21

The occurrence of severe adverse events (SAEs) in areaswith co-endemicity of Loa loa and onchocerciasis has beenone of the serious challenges APOC has had to face. SAEs can be very serious and sometimes even fatal.Research studies showed that patients with a high intensityof Loa loa infection were more likely to develop severeadverse neurological reactions following ivermectintreatment. Further studies revealed a close relationshipbetween the prevalence of high L. loa microfilarial loads inendemic communities and the prevalence ofmicrofilaraemia, and suggested that a microfilarialprevalence of 20% can be regarded as the threshold abovewhich there is an unacceptable risk of occurence of severeadverse reactions (SAEs) with ivermectin treatment.

APOC needed to find a way to identify communities at highrisk of severe adverse events (SAEs) with ivermectintreatment.

Based on a study in Cameroon and Nigeria in 2001 by TDR,the Rapid Assessment Procedure for Loa loa (RAPLOA) wasdeveloped and was approved by JAF. With the use ofindividual questionnaires the RAPLOA method makes itpossible to assess the prevalence of history of eye worm ina community. The Calabar swelling is one of the main

clinical sign of loiasis. A 40% prevalence of eye wormhistory being equivalent to 20% microfilarial prevalence,APOC has been able to map the areas where the risk ofoccurrence of severe neurological reactions is high in thecase of ivermectin treatment.

From 2002 to 2010, a total of 381,575 persons wereinterviewed in 4798 villages in 11 sub-Saharan Africancountries during RAPLOA surveys. Based on the results ofthese surveys and using GIS tools and geo-statistical analysismethods, a map of the estimated prevalence of eye wormhistory in Africa has been developed and shared with otherpartners in NTDs control/elimination programmes. Thismap is useful for oncho control and LF eliminationprogrammes for the following purposes :

- Plan training of community volunteers for early detectionof SAEs, - Train health workers in the management of SAE cases- Assist partners to provide support to health systems incountries by making available drugs and a minimum ofhealth equipment for the safe distribution of ivermectin.- Predict where ivermectin treatment for onchocerciasis canbe safely implemented

Map of the estimated prevalence of eye worm history in Africa

for safe implementation of CDTIRAPLOA - Mapping of eye worm (loiasis)

15 years of APOC


Stories from the field CBM

30 years working with CBM in ‘oncho country’

My first encounter with river blindness was in April 1969.At that time I was a young secondary school teacher atNavrongo Secondary School in Upper Region of Ghana. Iwas asked by the School Christian Fellowship if I would goand help plough some land for a village called Kulmasasituated in the valley of the Red Volta just North of Kongo.I was brought up on a farm in the UK and knew thefundamentals of ploughing. When I arrived at the village Iwas absolutely shocked to see that the only people in thevillage with any sight were children. All the adults were blind.Of course this village – like many of the villages in valleysall over the West African region – did not survive; much ofthe best farmland in the region was lost to onchocerciasis.By 1978, I had become the Principal of atechnical/vocational school in Zuarungu (Upper Region ofGhana), a school that undertook contracts in order to payits way. We were asked to build a rehabilitation centre atBinaba, a joint project between the Commonwealth Societyfor the Blind (now SSI) and the Christoffel Blindenmission(now CBM). The aim of the project was to train farmerswho had become blind through onchocerciasis to farm again– the main crops grown were onions, easily marketable.We built the rehabilitation centre and the late Mr KlausSeyffer (who later became CBM Continental Director forAfrica) moved in. My interest in the rehabilitation of farmersblinded by Onchocerciasis started at this point. I learnt thatCBM had developed a network of rehabilitation projects inGhana, Burkina Faso, Cameroon, Togo, Sierra Leone andDRC. These projects were all very successful and thousandsof farmers blind from onchocerciasis became productiveagain.In 1983 CBM offered me a position to work with blindpeople in Niger Republic. After an evaluation of thesituation, I set up a project in Tamou, south of Niamey, andonce again I was in ‘oncho country’. By this time, thanks tothe OCP (Onchocerciasis Control Programme) all fastflowing rivers had been sprayed to kill the ’blackfly’ thatspreads onchocerciasis. Every month, the helicopter wouldvery “faithfully” spray us (I lived near the river) and a teamwould come regularly, roll up their trouser legs in order tocatch specimens of the blackflies to test them. Other teamswould also come and “skin snip” the community membersto search for evidence of filaria (the parasite causing thedisease). I started a CBM supported programme to trainfarmers blind from onchocerciasis to farm again. I lived inTamou from 1984-1990 by which time the programme hadbecome cross disability and had spread as far as Niamey. Theprogramme (now called PRAHN) is still in existence andhas grown enormously, both in scope and in size.In 1994, I was asked by CBM to move to Abuja, Nigeria, totake up the position of Director of a community based

rehabilitation programme (CBR) with the CatholicArchdiocese of Abuja, and became country coordinator forCBM in Nigeria. One of the first activities that I undertookwas to organise the CBM onchocerciasis controlprogrammes in the FCT (Federal Capital Territory).Mectizan was now available and mass distribution began. Inthe FCT, distribution had to be done discreetly because wedid not want people in Lagos to use the fact that FCT was‘oncho country’ as an excuse not to move to Abuja!

By the following year CBM had also taken on theresponsibility of Mectizan distribution in Yobe, Kano andJigawa States, and by 1997 we had also started distributingin Taraba State – Here I was reminded of earlier days inGhana where in some villages 60% of the adults were blind.The work in Taraba was later taken over by a local NGO(MITOSATH). The success of the APOC programme inNigeria has been fantastic: it is now difficult to find peopleblinded by onchocerciasis in the states we are working in,and there is a real possibility that the disease will beeliminated.In addition to these marvellous oncho results, a system ofcommunity directed distribution of medicines and otherhealth interventions (CDTI / CDI) has developed to includetrachoma activities, distribution of Vitamin A, identificationof cataract patients and now lymphatic filariasis(elephantiasis) – what a fantastic success!!For the most part of my long stay in Africa , I seem to havebeen involved with river blindness control from the earlydifficult days (when the only treatment was banocide, amercury based treatment that made patients scratch untilthey bled) to the present day where cases of blindness fromonchocerciasis are increasingly difficult to find in many WestAfrican countries. I feel a sense of pride whenever I hear or read about theseoncho successes, and I count myself privileged to have beenpart of CBM’s contribution to oncho control in Africa

Mr Paul Caswell is Country Coordinator of CBM Nigeria

By Paul Caswell

Photo: CBM

15 years of APOC


Stories from the field Carter Center

23

Miracle Medicine Mends Nigerian Tailor's Eyesight

38-year-old Zaki Baushe holds a thin metal needle in his lefthand as he deftly angles a thread through its eye. As a tailorin Akwanga local government area, Nasarawa State, Nigeria,it is an act that he has repeated thousands of timesthroughout his life. Yet several years ago, Baushe was indanger of losing this skill entirely.

In 2006, Baushe noticed that his vision was fading and itbecame difficult for him to perform the simplest of sewingtasks. His blindness only worsened over time. Not knowingthe cause of his condition, he was forced to abandon his oldtreadle sewing machine. Each day he stood by helplessly,unable to return to the living that had sustained him and hisfamily.

Dr. Emmanuel Miri, resident technical adviser for the CarterCenter's health programs in Nigeria, discovered Baushe'scase during a routine visit to administer medicines inKambre. Listening to his symptoms, it was clear to Dr. Mirithat Baushe was suffering from river blindness, also knownas onchocerciasis.

Baushe was surprised to learn that his affliction was causedby the repeated bites of blackflies that swarmed near hisvillage. Through their bites, some of these flies haddeposited larvae into his body, which grew into parasiticworms. However, it was the offspring of these worms, calledmicrofilariae, that were the principal cause of his troubles.They swarmed under his skin, causing intense itching and

skin discoloration, and had migrated into his eyes--causinglesions that had damaged his sight.

Nigeria is the most endemic country in the world for riverblindness, accounting for as much as 40 percent of theglobal disease burden. It is estimated that up to 27 millionNigerians living in 32 endemic states need treatment for riverblindness.

Dr. Miri knew that he could change Baushe's life throughthe dose of a small white pill called Mectizan®. The drug,donated by Merck & Co. Inc., and distributed to the NigeriaNational Onchocerciasis Control Programme through TheCarter Center, safely treats river blindness by administeringMectizan which kills the microfilariae in the body. Not onlydoes the drug stop the progression of the disease, but it alsocan reverse some of the damage caused by the parasite.

After taking several annual doses of Mectizan, Baushe's sightimproved dramatically. He was able to thread a needle withease, and he returned joyfully to his work.

Since 1989, the Nigeria National Onchocerciasis ControlProgramme has grown from treating 49,566 people withMectizan its first year of operation, to the world's largestMectizan distribution programme. Annually, The CarterCenter now assists more than 5.5 million treatments innearly 8,000 villages.

By The Carter Center

Ph

oto

: C

art

er

Cen

ter/

E.

Mir

i

15 years of APOC


Stories from the field

In the early 1990s, fear dominated the community of Jaweparish, found in Mbale district, Uganda. The Jawe clan'sneighbouring parishes, Buryango and Bulweta, were beingplagued by an unknown ailment that attacked a person's skinand eyes. The disease left its victims unable to care forthemselves or their families.

At a community meeting in 1993, parish member EdirisaWangwenyi told the attendees about the disease that wasattacking their neighbours. He said the disease plaguedsufferers with skin like that of a lizard — very hard, dry, andpeeling off like a snake's skin. Its victims scratch themselvesnonstop every day and tear apart their bodies with stonesand broken pieces of pots. He described the sufferers as acursed race and warned all not to associate with them toavoid getting their sickness. The community membersheeded Wangwenyi's instructions, although many themselveshad unknowingly already been infected by the disease —onchocerciasis.

Five years later, the Jawe subcounty chief received a boxcontaining ivermectin tablets and was told that theycombated onchocerciasis. The parish chief selectedWangwenyi to distribute the medicine. Wangwenyi soon

learned that he and many others in his parish also had thedreaded disease. The instructions he received were clear:“Begin treatment with yourself ”.Wangwenyi walked house to house to distribute theivermectin, taking several months for distribution. Manypeople refused to take it, and some experienced side effects.Wangwenyi had to assure the people that the side effectswould pass, and that he too was taking the ivermectin.Treatment coverage in the community was low for someyears, in part because of resistance to taking the drug.

In the second year of distribution, two people per parishwere chosen to assist Wangwenyi, and communities wereempowered to make decisions on how to run theprogramme. The Carter Center came to assist the UgandaMinistry of Health in the programme and worked tostrengthen community structures through a kinship system.The use of kinship structures increased distribution andcommunity acceptance, and over the years the terriblemanifestations of onchocerciasis disappeared as treatmentcoverage improved.

Recently, Wangwenyi expressed his gratitude to The CarterCenter and other donors for their unending support. "Theprisoners of onchocerciasis have been set free," he said.

By The Carter CenterP

ho

to:

Cart

er

Cen

ter/

F.

Ric

hard

s

Edirisa Wangwenyi, one of the first village volunteers who

distributed ivermectin to fight onchocerciasis in Uganda,

stands in his home, which is filled with health education

materials and inspirational posters.

Ugandan Man Helps Rid HisCommunity of Onchocerciasis

15 years of APOC



25

Control of onchocerciasis in SierraLeone actually started in the late 1980sbut during the civil war (1991 – 2002)the National Onchocerciasis ControlProgramme (NOCP) activities dwindledand completely stopped by the end of1998. Results of epidemiologyevaluations carried out in the immediatepost-war period (2002 – 2004) showedthat the situation had not only worsenedin previously endemic areas, but thatonchocerciasis was now present in areaswhere none was noted in the past.Prevalence of onchocerciasis was still upto 80% in some places and activetransmission was still on-going.

Efforts to treat for onchocerciasis in2003 and 2004 were not successful, withtherapeutic coverage of just 35% and28% respectively, and very patchygeographic coverage. After the civilunrest was officially declared over in2002, the NOCP resumed operations in2003 under the Special InterventionZone (SIZ) project, which was managedby the African Programme forOnchocerciasis Control (APOC).Between 2003 and 2004 efforts to restartIvermectin delivery across the countryyielded very unsatisfactory results withtherapeutic coverage in 2004 below 40% (expected: 85%).

An investigation carried out by APOC in 2004 concludedthat the Community-Directed Treatment with Ivermectin(CDTI) was poorly understood and improperlyimplemented. Health workers were still distributingivermectin and geographic coverage was low. Poor onchocontrol in Sierra Leone presented a big risk for neighbouringcountries like Guinea which had a very low prevalence.

A complete overhaul of river blindness control in thecountry was the only answer. In 2005 the management ofthe NOCP was changed and its capacity strengthenedthough training. Cascade training on CDTI was carried out,social mobilization, health education and advocacy wereintensified, and community participation in CDTI was stronglypromoted, in keeping with the philosophy of the strategy.

Although there was support for these changes at the highestpolitical level, change was not that easy on the ground. Someof the district health workers were reluctant to hand overdrug distribution to communities, seeing a reduction in theirbenefits and upper hand as health personnel. A lot ofcoaxing and persuasion needed to be done. Most districthealth workers and CDDs had to be taught how to completereporting forms in the field. There were instances whenhealth workers reported that communities (CDDs) had notcome to collect drugs from the health facilities. Healthworkers needed to be shown how to encourage communitiesto participate more in CDTI, and were encouraged to payvisits to communities and discuss with the village chiefs toexplain the role of communities in CDTI.

By Joseph Koroma

oncho control in Sierra LeoneGetting back on track with

15 years of APOC



Sensitization was very important at this stage as properCDTI was being established for the first time in SierraLeone. Advocacy meetings were held at national and districtlevels and community meetings in all 8,451 communitiestargeted for CDTI each year to maintain community interest,acceptance of the programme and community participationin the implementation of CDTI.

The challenges were many: reaching some of thecommunities was arduous and perilous at times. Roads werebad and breakdowns of vehicles were common. Somecommunities had no literate people who could report welland help had to be sought from neighbouring communities.CDDs were dropping out because most expected paymenteven though it had been clearly stated at the first communitymeetings held that there would be no payment to CDDsNew CDDs had to be appointed by community members

but some communities were notkeeping the promises made to CDDsand this de-motivated CDDs. Someitems such as T-shirts, and fliers thatserved as a means of identifyingresidences of CDDs were provided tomotivate CDDs, and this gave them asense of pride.

The many side effects, (though mild),that occurred when treatment firststarted, discouraged many from takingIvermectin. More sensitization neededto be conducted at community meetingsto explain that such adverse reactionswould reduce with each treatment.Since 2005, the NOCP has conducted 6annual mass drug administration (MDA)using the CDTI strategy. Therapeuticcoverage has increased from 54.8% in2005 to more than 65% since 2006.Geographic coverage also improvedfrom 64.3% in 2005 to 98.5% in 2006and since 2007 has been maintained at100%. Because of the success of CDTIin Sierra Leone since 2007 the NOCP isnow also responsible for treatment ofneglected tropical diseases (NTDs) inthe country, using the CDTI structureas a platform.

When I was appointed programmemanager in February 2005 the pressure from top officials atthe Ministry of Health and Sanitation, supporting Partnersand the international “oncho world” to turn things aroundin Sierra Leone within a short period was enormous. Thefact that we (the oncho control team) had very limitedknowledge of CDTI made it all seem such a daunting task.However with the support of health workers, affectedcommunities, and international partners who had experienceof the CDTI strategy in other countries as well as constanttechnical support from APOC we were able to meet thechallenge.

Today, though we are not quite there yet, I know that withthe help of our donors and partners we will get there.

Dr. Joseph B. Koroma is APOC Technical Adviser in Sierra Leone

Oncho control in Sierra LeoneGetting back on track with

Bad roads: Big challenge during the rainy season

Community meetings on CDTI in Rotifunk

Moyamba district

cre

dit

to

NO

CP

SL

E

credit to NOCP SLE

15 years of APOC



27

Successive conflicts in the country had weakened theexisting health system, with a total dismantling of healthinfrastructures in the conflict areas. The Community-Directed Treatment with Ivermectin (CDTI) project in CARwas destabilized, and APOC and the NGDO partner wereforced to suspend support to CAR in 2003.

Activities only started again in 2007 with the NGDO partnerCBM fully on board. I was appointed technical adviser toprovide assistance and help to rebuild the CDTI project.

There was indeed a lot to be done to get the project workingagain. Technical activities included training and retraining inthe CDTI strategy; REMO and RAPLOA surveys tocomplement information required for drug distribution foroncho and also the occurence of Loa loa.

Apart from technical and administrative challenges I alsohad to face certain emotional challenges such as dealing withthe mistrust on the part of others already working in theproject, as well as find ways to manage cultural and linguisticdifferences.

Everywhere I went, whether at central level, or in theregions, prefectures or sub prefectures the first challengewas to ensure that I was accepted by my counterparts. Ineeded to win their confidence, and prove very quickly thatI had the necessary expertise that would be a definite plusfor the restructuring of the programme and re-launching ofactivities.

My most enriching contact was with the community. Themeetings held in different areas of the project made merealize that whatever the nationality or the ethnic group,these humble communities only wanted to be involved inwhat they were being asked to do, that is, take charge of theirown health using the CDTI strategy as a vehicle.

The case of Mr. Janvier Jean a community distributor(CDD) in Ndomété, central CAR, illustrates how committedthe community is to the CDTI project. Mr Janvier has beena distributor since the start of the programme in the countryand uses biblical terms as inspiration. He loves to say that“he is waging a crusade against disease and poverty”.During a meeting with some members of the communityhe asked the coordinator of the NOTF for his “support”.Before the coordinator could reply, a woman (communitymember) told the CDD that he should not wait for projectmanagers to come from the town to ask such questions, andthat the solution to all such problems will be found whenthey have been discussed by the community with the chief.This shows that the question of acceptance of CDTI andinvolvement of community members in the strategy is nota problem.

Has oncho control in CAR been a success? I think we cansay, ‘yes, it has, but!’ It would be asking too much to expectthe country to be at the same level as other APOC countriesconsidering the many conflicts CAR has had to endure.However, the disease burden is lower now than at the startof activities. With the assistance of APOC and the NGDOand other partners as well as renewed political will toincrease government financing these challenges will be met

The key to establishing a sustainable CDTI programme liesin getting all actors to realize and accept that this is not just

another health programme but a tool that offers theopportunity to expand their actions to the control ofneglected tropical diseases in order to enhance the well beingof their most vulnerable populations.

Mr Moussa Sow is APOC Technical Adviser in CAR.

Contributing to the re-launch of CDTI activities in the CentralAfrican Republic (CAR) after the war.

By Moussa Sow

15 years of APOC


Stories from the field Implementing CDTI in South Sudan

By Benjamin Atwine

Two decades of civil strife have had an enormous toll on theestablishment of health systems in Southern Sudan especiallyat the community level. Community cohesiveness, however, isquite strong and the spirit of volunteerism to implement CDTIactivities exists especially among individuals who have hadpersonal experience with the effects of the disease like havinga parent go blind. In addition, there is a strong system ofcommunity chiefs and leaders that is highly respected by thecommunities and this is a good entry point for mobilising andsensitizing for CDTI. Even though the level of performanceof the CDTI projects is still not yet what is expected after thenumber of years it has been implemented, there is a gradualand steady improvement in geographic and therapeuticcoverages as shown in the graph below.

The trend of the achievements made in treatment by theSouthern Sudan CDTI projects

In spite of these improvements in coverage rates the challengesin CDTI implementation in Southern Sudan are many:• Despite the situation being calm most of the time, there isalways the fear of insecurity reigning again because of thegeneral high level of lawlessness and extremely high culture ofconducting revenge attacks. The common causes of conflict

arise from competition for resources for the grazing oflivestock between different groups of nomadic pastoralists,and also between pastoralists and agriculturalists. Populationdisplacement and even deaths are common following conflictswhen cultivated feeds are grazed upon. Such incidences arecomplicated by counter attacks and destabilize the community.Southern Sudan is quite vast in land area and the roadinfrastructure is generally not in a good state. Thoughconstruction of paved roads has begun in the capital city and

along a major highway connecting to Uganda, the rest of thecountry only has seasonal roads that occasionally get washedaway by heavy rains. Movement in the project areas in therainy season is highly limited because of the state of the roadsand the fear of getting stuck. This means that most activitiesneed to be implemented during the dry season. Unfortunatelythis does not synchronise quite well with the APOC fundingand disbursement cycle which means that some activities areimplemented in the rainy season.

• With a sizeable proportion of the beneficiary communitybeing involved in cattle rearing activities, there may be a needto change the approach used in order to get these communitiesto receive their mectizan®. In the drier months of the year,pastoralist families move to grazing areas commonly calledcattle camps, as shown in the picture below where hundredsof animals are grazed. This is a major reason cited for missingtreatment in the past.

As in any other developing country, the majority of thepopulation resides in rural areas and their main occupations inthese rural communities are subsistence farming and nomadiclivestock production. Nomadic cattle keeping is mainlypractised by the Dinka and Nuer communities who have greatsentimental attachment to their cows. In the rainy seasons

where there is plenty of pasture their cows are grazed aroundthe usual human settlements. Huge huts are built to protectthe cows from being rustled by rival communities. Such hutscan house between 50 -100 cows that get loosely tetheredaround their necks to roof-tall poles

Dr Benjamin Atwine is APOC Technical Adviser in South Sudan

15 years of APOC



29

This true story takes place in a village during anepidemiological survey in the north of Benin during thetransition period when ivermectin was being introduced tocontrol onchocerciasis. Mr Aboudou Lawani, Team Leaderof the epidemiological evaluation at the time talked of avillager, still in the prime of his life who had started todevelop blindness. Over the years, and each time anepidemiological evaluation was done it was noticed that theblindness was getting worse and that the gentleman couldsee less and less. He always complained that he could notunderstand why he was being asked to do biopsies everytime when no one had tried to solve his real problem- curehis blindness.Explanations about the larviciding treatment being carriedout calmed him and convinced him to continue acceptingthe biopsy. But clearly he was getting more fed up with beingasked to do so many biopsies.When at last the country teams were in possession ofivermectin, it was with great joy that the Benin team arrivedat this village to carry out surveillance in conjunction withfree mass treatment with ivermectin. At last they could nowgive some help to the gentleman whose eyesight was getting

worse. On arrival at thevillage during thesens i t i za t ionsession with thevillage leadersand elders onthe eve of thedistribution theteam noticedthat the villagerin question wasabsent.When askedwhere he was they were informed that his blindness hadbecome so bad that he could no longer move around byhimself. The team leader asked to be taken to this villager’s homewho asked him who he was and what he wanted. After theexplanations of the team leader and at the news of thearrival of the drug the villager wanted to know whether itwould help him recover his sight.

The team leader had to say noand explain that the purpose ofthe drug is to prevent blindnessand stop transmission of theinfection. The old man wasvery disappointed as was theteam leader because he had somuch wanted to help this man.The cure had come too late. This true and sad story showsthat we in oncho control havea duty to ensure that ivermectinreaches everyone who needs it,wherever they are, in time toprevent blindness and othersuffering and hardship.

Dr Franck Sintondji is APOC

Technical Adviser in Chad

By Franck Sintondji

The importance of getting ivermectin to those that need itin time to make a difference!

15 years of APOC


Stories from the field ADB

My visit to some villages in the Esse District of Cameroonin April 2011, (my first firsthand experience of onchocontrol activities on the ground) gave me a lot of food forthought, especially as regards the concept of volunteerismin developing countries, and also the selflessness of healthworkers.

The involvement of pensioners in CDTI activities was quiteremarkable. A good number of pensioners from the city haddecided to return to their villages after several years livingin urban settings, with a different and more modern lifestyle.Re-integration into village life, in the tropical forest with itslush, peaceful and restful vegetation appeared to have beeneasy, and must have facilitated the involvement of thesepensioners in community activities such as the fight againstonchocerciasis. These volunteer pensioners (CDDs andordinary members of the community) are examples of anew generation of volunteers. Since these pensionersalready have their personal income this reduces, to an extent,the problem of incentives, especially monetary incentives.

However, this begs the question: what is the ideal age for aCDD? Is it better to recruit young people, often unemployedand unskilled, and more likely to leave the village at the firstopportunity to work elsewhere, but who have the advantageof being more fit, given the distances that sometimes haveto be covered to do community work. Or, older people, suchas pensioners, who are more readily available, with less

constraints and expectations about incentives, but who mayfind it more difficult physically if there are long distances tobe covered to conduct sensitization activities. Luckily, thecommunities themselves solve this dilemma since theychoose their CDDs themselves.I was greatly impressed by the commitment and passion ofa CDD; a pensioner in one of the villages that I visited.During our conversation he talked passionately about hiscommitment to serve his community and his desire to comeback to his roots and enjoy the benefits of a peaceful life,and his wish not only to help his community but also tobelong (to it again). This is an opportunity that the APOCprogramme should look into and develop as a channel foradvocacy and sensitization.

I also noticed the difficult conditions under which the healthstaff were working; in this area there was just one nurse foreach health post. Difficulties included the very environmentin which they were working, travelling in the area alongnarrow paths that are probably impossible to cross duringthe rainy seasons. The search for quality in the delivery ofservices, despite the many challenges, to better respond tothe needs of the community in the fight againstonchocerciasis, as well as the desire to provide other supportto communities are clear testimonies of a dedication thatnowadays is not always found among medical personnel inurban areas.

As staff of a partner organization(the African Development Bank -ADB) of the programme, this fieldexperience gave me a clearer insightinto the difficulties and sociologicalrealities of oncho control activitieson the ground. The ADB supportsand funds national and regionalpoverty reduction strategies andstrives to reduce or solve theproblems of human development ingeneral, and the CDTI fits aptly intothis framework.

Dr Maimouna Diop-Ly is Principal HealthAnalyst at the African Development Bank

By Maimouna Diop-Ly

Close view of CDTI activities in the field

15 years of APOC


Stories from the field In their own words

31

Joseph Edogbo. 89 years.Umomi community Ofu LGA, Nigeria.Kogi State CDTI.Kogi State Ministry of Health.

“I know some people in our community that are blind butthe cause of their blindness I do not know because I amnot health personnel. I came to know about river blindnessas a result of awareness created in our community byhealth workers. The signs of this disease are discolourationof the skin, nodules, itching and a poor eye vision. Beforewe started treatment with Mectizan it was Banocide, andfor more than 10 years now we have been using Mectizantablets. Since the commencement of treatment I havenever heard of any case of blindness in this community”.

“People in the community realised the need for them tobe treated, though some individuals in the past did rejecttreatment due to drug reaction. I as a person can now readmy Bible due to improvement in my sight as a result oftaking Mectizan tablets. The town crier does announcearrival of the drug, when distribution would take place andfor every person to be around, thereafter people will betreated by Paul our distributor from house-to-house”.

Sightsavers

Agnes Tabi of Nfaitock Village, Cameroon

“Before I took Mectizan® I had a rash on my body and myskin would itch. I used to see ‘threads’ in my eyes andsometimes I was scared I would lose my sight. It was thesame for lots of the other villagers. But since the Mectizan®distribution has started these problems have reduced.

“I’ve taken Mectizan® for four years and now I feel fine. Ihave no itching and nothing is wrong with my eyes. All myseven children and my many grandchildren take the tablettoo and none of them has a problem with their eyes. Oneof my sons helps distribute Mectizan® to theneighbourhood. “Before the programme began there were blind people inNfaitock, but now there are fewer and the eye sight of thevillagers has improved. Everyone in the village knows aboutthe drug and is anxious to keep taking it.”

Sightsavers

RIVER BLINDNESS

CASE STUDYAGNES’ STORY

Agnes with one of her grandchildren

Joseph Edogbo is married with 4 children and 9 grandchildren.

Photo: Suzanne Porter/Sightsavers

Photo: Suzanne Porter/Sightsavers

Dr Daniel Shungu is Executive Director of UFAR

15 years of APOC


Support for oncho control from across the ocean

LOCAL SIXTHGRADER SELLSHIS HAIR TOADOPT VILLAGEIN CONGO

Marco Kaisth, a WestWindsor sixth graderat Grover MiddleSchool, recentlyraffled off a haircut,one curly lock at a time, to fellow students. His fundraisingyielded more than $100. Matching funds from hisgrandparents and an additional donation brought the total to$250, enough to adopt the 551-person village of Mulangabalain the Democratic Republic of the Congo. The adoptionfunds the treatment of river blindness. Presenting theadoption certificate is D’Anne Hotchkiss, chairperson of theboard of UFAR

By Daniel Shungu

US citizens making a contribution toonchocerciasis control in DRC

LOCAL NINE-YEAR-OLD BOY ADOPTS VILLAGEIN THE CONGO

Nine year old JamesSchultz decided toforego a computergame for himselfand instead donatedthe $250 to adopt avillage in theD e m o c r a t i cRepublic of theCongo (DRC).Sunday night hepresented his gift toDr. Daniel Shungu,Executive Directorof UFAR. With hisdonation, UFAR will distribute a full year’s treatment to fightriver blindness in a village in the DRC.

MIDDLE SCHOOL STUDENTS PROVIDETREATMENT FOR RIVER BLINDNESS FOR AVILLAGE IN AFRICA

The Hun Middle School was recently recognized andthanked by Ms. Jean Jacobsohn, treasurer of UFAR, forits efforts to raise funds that brought medication to all654 inhabitants in the village of Kabove. The MiddleSchool began a collection last year to support UFAR. Middle School students were taught about river blindnesslast year when UFAR representative Dr. Daniel Shungudiscussed his work in the Democratic Republic ofCongo to combat river blindness. Following this school-wide presentation, teachers at the school continued thelessons about river blindness and students wereencouraged when they learnt that a donation of $250made it possible for an entire village to receivemedication. Students began a Middle School penny warto collect money and they successfully raised anddonated $250 to UFAR.

Presentation of a certificate to Marco for

adopting the village of Mulangabala, DRC.

American church members - strong supporters of UFAR’s mission in DRC

from the very beginning. - Ready for Mectizan distribution in the village of

Samboa, RDC,.

Presentation of certificate of village adoption to students at The Hun

Middle School, Princeton, USA: who adopted the village of Kabove, DRC. Photo of Dr Shungu and James, who forgo buying a

computer game with his pocket money and decided

to adopt a village.

Determining the dose of Mectizan by height in Samboa, DRC.

Photo: UFAR

Ph

oto

: U

FA

R

Photo: UFAR

Ph

oto

: U

FA

R

Ph

oto

: U

FA

R

15 years of APOC


Travelling for APOC

33

August 1997 – Roughing it at Jeddah Airport (Saudi Arabia)

In August 1997, Dr J.B. Roungou, Dr Uche Amazigo, Dr M.Noma and I travelled to Khartoum via Abidjan, AddisAbaba and Jeddah, to organize the first workshop on APOCPhilosophy and CDTI strategy in Sudan and open anImprest account. We knew before we left that getting to ourdestination was going to take several days but we thoughtwe would spend these days either in the aircraft or in a hotel. This expectation fell flat when our flight from Addis Ababato Jeddah was delayed. By the time we arrived in Jeddah, ourconnecting flight to Khartoum had already left. Since wehad no visas we were not allowed to leave the airport tocheck into a hotel. Our UN Laissez-passer (UN diplomaticpassport) did not soften the hearts of the immigrationofficers, and we had to spend 72 hours at Jeddah Airport(there was no connecting flight for three days!) sitting on thebenches in between catching some restless sleep. There wasof course no shower facility at the airport so you can justimagine how self-conscious we were all feeling about thesweat under our clothes!! We tried not to complain too muchbecause at least we were given food three times a day. Whata relief to be able to finally leave on the third day. Needlessto say when we arrived in Khartoum we were completelyexhausted, but we did reach the end of the road…...

July 1998 – Saved by the baby’s cries , or what???Three of us left Ouagadougou one Thursday morning inJuly 1998 for Blantyre in Malawi via Abidjan, Nairobi andLillongwe to train oncho programme officers in the WHOimprest and management of APOC Trust Funds. Thejourney from Ouagadougou to Abidjan was smooth. Ourtake off with Ethiopian Airways from Abidjan that eveningwas also normal. About an hour after take-off, just when wehad started eating dinner the pilot announced that due tosome problems, he was returning to Abidjan. We were notallowed to finish our dinner because the hostesses cameround to pick up our trays. Every one went silent and all we could do was look at eachother. Some people started to pray. A strange thinghappened on the plane. When we took off from Abidjan ababy started crying and neither her mother nor the hostessescould get him to stop crying. However when the pilot

announced that we were going back the baby suddenlystopped crying. When we landed at Abidjan we learnt thatone of the engines of the plane had stopped working. Wethanked God for saving us. We had to wait in Abidjan tillthe next evening to continue our journey. We had, of coursemissed all our connections but we did get to our destination,Blantyre even though we arrived totally exhausted and it hadtaken us three days!!

May 1999 – How ever did we survive without cellphones before?Compared to other missions this one was quite uneventful.Except that in 1999 being in Kabale, South Uganda meantyou were completely cut off from the outside world. It wasbefore the advent of cell phones, and telephonecommunication with the outside world was a majorchallenge. My daughter was born, back home inOuagadougou, on 3rd May and it was only when we gotback to Kampala on 9th May that I got this happy news!!

February 2002 – Reaching the end of the road even inconflict timesOne of my most exciting missions was the one with theformer NGDO coordinator Dr Pamela Drameh toKisangani to set up the Tshopo CDTI project and otherCDTI projects in the Northern part of the DemocraticRepublic of Congo. At that time rebel groups occupieddifferent parts of the country. Kisangani also had its ownrebel group. We flew to Nairobi via Abidjan, and in Nairobi we had tocharter a cessna plane to Kisangani via Kigali and Entebbe.The plane was obliged to fly at a low altitude with the riskof being shot down by opposing rebel groups. There wasno proper hotel when we arrived and we had to stay in ahouse transformed into a hotel, without electricity. We hadto make do with candles and torches for the night. Apartfrom UN vehicles, the only means of transportation at ourdisposal were bicycles. During our stay, we had to pay acourtesy call on the rebel leader. When we were not worryingabout being shot down we took time to enjoy the sights andit was quite exciting to fly over the tropical rain forests andLake Victoria from Entebbe up to Nairobi.

By Yao Aholou

APOC prides itself on getting vital services and products to the people who need them most, whereverthey are, usually at the end of the road, and whatever the odds - In peace time, in war time, throughbad roads, across rivers, on hungry stomachs…..CDDS often have to trek many miles through very difficult terrain, most times on foot, to distributeivermectin to community members. APOC staff sometimes does not have it any easier, but wouldchange nothing about these difficult but exciting trips.

These are their stories...

Ensuring training on the CDTI strategy, APOC philosophy and WHO financial reportingsystem in countries

15 years of APOC


Travelling for APOC

August 2004 – Adventures in post-conflict Rumbek,Southern Sudan

This mission was a life-forming experience in itself. Six ofus, Dr Amazigo as team leader, Prof Eka Braide, Dr A.Hopkins, Mr Chukwu Okoronkwo, the late Ms Nene Keita,Ms P. Mensah and I had to go to Rumbek in South Sudanto conduct training on APOC philosophy and financialrules. We first flew to Nairobi via Abidjan and from Nairobito Lokichogio in North Western Kenya where we had tohave a security briefing in a UN humanitarian camp beforeproceeding the following day to Rumbek on a UNhumanitarian flight.

We had no problems landing and taking off fromLokichogio but landing in Rumbek was another matteraltogether. What served as a tarmac was only a pavedlateritic road and we could see crashed planes when we werelanding. By some miracle and the skills of the pilot welanded safely. There was no hotel in Rumbek at that timeas all infrastructures had been destroyed during the war. Wewere taken to a big camp where the workshop was to takeplace.

We had to sleep in tents in which snakes could easily enterand we needed to queue to use the toilet or take a shower.Our workshop was held under the shade of a tree. It rainedone day during the workshop and we had to use plasticsheets to cover our photocopier and projectors and wait forthe rain to stop before we could continue with theworkshop. One evening, when we were going back to ourtents, my colleague, the late Ms Keita, fell into a pit becauseit was dark. We were worried she could be bitten by snakes,but thank God there was none in the pit. We had to call theguards to lift her out!! What an experience that was.

Travelling for APOC, trying to reach and serve the poorest

of the poor is, at times, quite challenging but I would notchange it for the world, for each experience has helped megrow. I am deeply grateful for the opportunity to contributeto the work of the APOC programme and make adifference, however small…..

Rumbek

Airstrip

Conference hall in Rumbek

Our bathroom

Our hotel room

Mr Yao Aholou was Administrative Officer at APOCfrom October 2001 to December 2010

15 years of APOC


Travelling for APOC Adventure in Taraba State, Nigeria

35

In May 2009 just before joining APOCas a full time epidemiologist I wasasked to be part of a team who washeading out to the Taraba State CDTIproject in Nigeria to conduct anepidemiological evaluation. Thisseemed like providence to me, a kindof God-sent opportunity for me to getsome first hand field experience fromOCP technicians who had beenworking in the area for decades.

This was my first time to go to Nigeriaand I must confess that travelling in thecountry scared me some having heardso many stories of some of thechallenges of travel in that vast country. Still I took mycourage in both hands and decided to give it my best shot.When I landed at Lagos international airport, I had tocontinue by domestic flight and car from Lagos to Jalingoto join the team in Taraba.

The plane made four stopovers before finally landing in Yolain Adamawa State five hours later. I was exhausted and all Iwanted was a bed so I could lie down and rest. Unfortunatelythe journey was not over. This time it continued by car. Iwas not used to the weather and the heat was unbearableespecially in Maiduguri a Northeastern town in the NigerianSahel. We arrived in Jalingo late at night after a veryexhaustive and long day. Taraba State in Nigeria is named after the Taraba Riverwhich traverses the southern part of the state and its capitalis Jalingo. The state was created out of the former GongolaState on 27 August 1991, by the military government ofGeneral Ibrahim Babangida. Taraba State lies largely withinthe middle of Nigeria and consists of undulating landscapedotted with a few mountainous features. These include thescenic and prominent Mambilla Plateau. The state lies largelywithin the tropical zone and has a vegetation of low forestin the southern part and grassland in the northern part.

I confess I only saw this beautiful landscape later. To tell thetruth I was not particularly interested in looking atlandscapes at that time of the night. In addition to myextreme tiredness hunger pains were now tormenting me. Ihad only had a slice of bread and a coke in the plane andmy stomach felt as if nothing had gone into it for two days.I was looking forward to a plate of goat pepper soup andrice, which I had been told is a specialty of Nigeria. Imaginemy disappointment when we reached our lodgings only tobe told that the restaurant was closed for the night. I had togo to bed hungry, and of course sleep was not very restful.We had to start our trip early the next morning to join theteam in one of the Gashaka LGA, so no breakfast either.We managed to buy some ground nuts and bananas at theroadside on the way. At noon we reached the rest of the team who were alreadywell into the epidemiological evaluation. After a warm butbrief introduction to the other members and a briefexplanation about the procedure I was attached to a subteam to work with them. We spent the whole day out in thefield until it got dark and the microscopist could not seeclearly to read the slides. By the time we got back to the smallLGA town Gashaka at 9:00 pm all the small restaurants wereclosed. I had to go to bed hungry again. Clearly this trip wasnot going well for me, at least not as far as food wasconcerned !

By Hailemariam Tekle Afework

Section of ‘the road’ to Gangumi village

Adventure in Taraba State, Nigeria – travelling on an empty stomach by air, by land and by river...

15 years of APOC


Travelling for APOC Adventure in Taraba State, Nigeria

The next day brought another challenge. Weneeded to get to Gangumi village on the bank ofthe river Taraba, to continue with our epievaluation. We had already sent a local messengeron a motor bike to the community the day beforeto ask for an appointment for us to meet with theentire community. The messenger went by motorcycle and returned late at night and told us we hadan appointment at 8:00 the latest. We planned toset out early in the morning at 6:00 am as we hadbeen told that the roads were bad. “Bad” turnedout to be an understatement. It took us more thanfour hours to get to the bridge that was fivekilometres from the village. And when we got therethe bridge was broken and we could not pass!Frustrated with the situation we had to get backto the town late in the afternoon without doinganything. With the patience of true professionalson a mission we sent the same messenger to thecommunity to explain what had happened and torequest another appointment, convenient forthem..Forewarned is forearmed so the next visit wedecided on another route and crossed over to thevillage by boat. We had to leave our cars with thedrivers on the river bank and carry all the tables,chairs, microscopes, forms, medicines to thevillage.

The broken bridge near the village of Gangumi

Crossing Taraba River by boat

His Royal Highness of Gangumi, the village leader receiving

the evaluation team at his palace. His Royal Highness is blind

from onchocerciasis. He expressed his satisfaction and joy

and gratitude for what the onchocerciasis control program

was doing in his village because he said he wanted his

children and great grandchildren to always be free of the

disease

Walking towards the village carrying the evaluation team equipment

Dr Hailemariam Tekle Afework is Epidemiologistat APOC

15 years of APOC


Travelling for APOC Testimonies from communities

37

Mr Zinnah M. Barcolleh has been serving as community DirectedDistributor for the past four years. Mr Zinnah is responsible forJapan community and it takes about one kilometre walk to coverthe target population of his community .He said his greatestmotivation is his desire to serve his community in line with hisambition to become a nurse in the nearest future. According toMr Zinnah he will continue to serve his people as long as he isresiding in the community especially as other people are not toocommitted to do the work. Besides onchocerciasis he is involvedin diarrhea control and health education in the community. MrZinnah is very grateful for the bicycle donated by APOC throughthe Ministry of Health and the County Health team. It has helpedhim to overcome the problem of the far distances to reach morepeople in 2010 compared to the last treatment round.

Mr John B. Sacki is a 30 year old farmer, married with children.He started serving as a CDD in 2009. Mr Sacki covers Wodee andother surrounding villages in the Todee health District ofMontserrado County in the North West CDTI Project. He saidthe bicycle provided to him by APOC is helping him to reach fardistances, and more people were treated in 2010. According toMr Sacki “ the distances we cover are not easy, especially wheremotorbikes or bicycles cannot pass”. However he pledged tocontinue to serve his community “ I am prepared to continue toserve my people, I only need their help for my farm work”. Herequested advocacy to the town chiefs to help with communitysupport.

Mr Perry S. Yarkpawolo age 42, married with four children is afarmer and casual worker with medicins du monde, one of thehealth NGOs providing assistance in his community. He startedto serve as a CDD in Belefanai community in Zota Health Districtin Bong County in the year 2000. He has been a CDD for overten years. He said with the help of the bicycle his treatmentcoverage increased in 2010 compared to previous years. This heattributed to his being able to reach numerous households ofabout 2,376 people scattered over a wide area more easily thanbefore. He said he is committed to serving his people, andexpressed happiness over the selection of four more CDDs bythe community to join the Mectizan distribution in his communityin 2010.

Mr. Perry Yarkpawolo, CDD Belefanai community in Zota Health District in Bong County

Mr John B. Sacki, CDD Todee health District of

Montserrado County in the North West CDTI Project.

Mr Zinnah M. Barcolleh, CDD in Montserrado County

of the North West CDTI Project.

Community-drug distributors (CDDs) often have to travel long distances to administer ivermectin orprovide other health interventions to members of their communities. Many CDDs have indicatedthat bicycles would help them greatly with their work by making it easier and more efficient as theywould be able to complete their tasks in a shorter period of time.

Furthermore, bicycles could be used to help communities in many other ways such as obtainingmedical assistance for women during childbirth – something which could be life-saving in view ofthe high maternal and infant mortality prevalent in many rural areas.

For these reasons, APOC provided funding to purchase bicycles and presented them to selectedCDDs in Tanzania, Liberia, Nigeria, the Democratic Republic of Congo, and the Central AfricanRepublic. The purchase of bicycles was supported in part by the Global Fund for Neglected TropicalDiseases through a kind donation via the Sabin Vaccine Institute in 2009, of US $250,000. Thefollowing testimonies are from long-serving CDDs in Liberia who received bicycles.

By Ukam Oyene

Mr. Ukam Oyene is APOC Technical Adviser in Liberia

15 years of APOC


Partnering with APOC CBM

Onchocerciasis and other Neglected Tropical Diseases(NTDs) present a largely hidden burden affecting the mostmarginalised and voiceless communities living in poverty andconflict zones. They disproportionately affect children,women and persons with disability, keeping individuals andcommunities trapped in a cycle of poverty.

CBM is working globally with partners in 70 of the poorestcountries (population 4.6 billion people) in which almost 500million persons with disabilities live. They are the purposeand focus of our work.

CBM has been successfully involved in prevention ofblindness from onchocerciasis for more than three decades.We closely collaborate with communities, APOC and otherpartners and stakeholders.

CBM supports the annual treatment with ivermectin throughcommunity directed intervention (CDI). We are mainly activein Nigeria, Democratic Republic of Congo, Central AfricanRepublic, Burundi and Southern Sudan.

CBM first received Mectizan for individual treatments fromDr Gaxotte of Merck in 1988. By 1990 CBM was workingwith other international NGOs to form the INGO(International Non-Governmental Organisation)Onchocerciasis Coordinating Group in order to planMectizan distribution programmes in Africa, reaching 7million treatments per year in 1994. In 1994/5 the INGOgroup entered into a global partnership with Merck, WHO,the World Bank and 19 countries in Africa to establish theAfrican Programme for Onchocerciasis Control. In 2009CBM supported 8,411,288 treatments with ivermectin throughCommunity Directed Intervention (CDI) programmes.

In our experience, the greatest challenge is working in fragilecountries with poorly functional health systems. Weak healthsystems severely affect both co-implementation andintegration of onchocerciasis programmes within PrimaryHealth Care (PHC). While the active role of well-trainedCommunity Directed Distributors (CDDs) is essential forsuccessful programme implementation, high attrition, genderimbalance, and maintaining good motivation can be seriouschallenges for programme coordinators. Makingonchocerciasis programmes more sustainable will be crucialin preparing for the proposed transition from control toelimination where feasible.

APOC is rightfully seen as one of the leading public healthsuccess stories in Africa. Ownership by committedgovernments and a community-directed approach have ledto high geographic and therapeutic coverage, even in often-difficult circumstances. CBM’s experience with using CDIstructures for primary eye care interventions e.g. in the DRCand Nigeria, demonstrates the effectiveness of such add-oninterventions.

The APOC partnership model and the lessons learnt throughits implementation, its community-directed and its evidence-based approach have resulted in the most outstanding successstories in onchocerciasis control. They have contributed tostrengthening national health systems (with a focus on PHC)and to developing programmes tailored to specific situations.

Dr Martin Kollmann is Programme Director for NTDs, CBMCentral Africa Regional Office

By Martin Kollmann

Working with the poorest of the poor: CBM’s experience and

commitment in the fight against river blindness

15 years of APOC


Partnering with APOC SSI

39

Sightsavers’ work in onchocerciasis goes back to the 1950swhen our founder, Sir John Wilson, did a lot to highlight thedisease to the international community by supporting muchof the early research into the disease. Indeed, it was Sir Johnand Lady Wilson who first coined the name “RiverBlindness” for the disease. Early work in Sightsavers-supported projects in Mali, Nigeria and Uganda led to thedevelopment of community-based treatments which went onto become the backbone of onchocerciasis controlprogrammes in Africa – community-directed treatment withivermectin.

Sightsavers have been involved with the APOC partnership(and before it OCP) since inception. In 2010 we celebratedour 150 millionth treatment with Mectizan in our supportedprogrammes. From about 5 million supported-treatments in2009, we now support the treatment of 22 million people in14 African countries. Without the donation of Mectizan® byMerck and the partnership that APOC facilitates betweendonors, governments and communities, we would not havebeen able to reach such levels of supported treatments.

Sightsavers is keen to move from control to elimination inour supported projects where this is feasible, and within theguidelines that APOC has agreed. We are developing a ‘fasttrack initiative’ for onchocerciasis elimination in oursupported projects – this plan will highlight the additionalareas of programme development we need to support (e.g.surveillance and even supporting new countries and projects)to make our contribution to the elimination of the disease inAfrica.

Our contribution to the overall treatments in Africa isimportant for Sightsavers – we believe that partnership andcommunity ownership will lead to a long-lasting legacy forAfrica.

For me, communityownership and partnershipare embedded in our supportto the training ofCommunity Directed Distributors (CDD). Recently on a tripin Zamfara State, Nigeria I met Mr Usman Malamai. MrMalamai has been a CDD for 16 years in Fulfuri – this is thelength of ivermectin distribution in his community. In hisperfectly kept record books is the evidence of treatment andcoverage that will support the proof of concept ofelimination of the transmission of onchocerciasis in ZamfaraState. My trip to Zamfara in December 2010 also highlightedthe real potential that community directed interventions canoffer to global health.

The state, with support from Sightsavers and other partners,has mapped the state for onchocerciasis, trachoma, soil-transmitted helminths and schistosomiasis. This is the firsttime this has been done in any state in Nigeria. The state,with support from Sightsavers, then set about delivering massdrug administration for the diseases through community-directed interventions and school-based treatments. Again,the first time this has happened in Nigeria. The extra cost todeliver drugs for the five focus NTDs for Africa to apopulation of about one million is minimal given the strengthof the partnerships between the state and Sightsavers, thedonated drugs and the delivery ‘vehicle’ that community-directed interventions offer. Programme partners are alsostarting to investigate the potential to involve CDDs in thedistribution of bed nets against malaria.

As APOC moves from a control programme to anelimination programme Sightsavers is ready to continueplaying our part in the most successful public-privatepartnership for health in Africa.

Mr Simon Bush is Director of Advocacy andAfrican Alliances at Sightsavers

By Simon Bush

Sightsavers and oncho control – a long standing partnership

Mr Usman Malamai a CDD of 16 years

service in Fulfuri, Zamfara State, Nigeria

(Ph

oto

: Do

min

ic H

asla

m/S

igh

tsavers

United Front Against River blindness (UFAR) is anAfrican-inspired US-based nonprofit organizationinvolved since 2006 in the national programme

for the control and eradication of onchocerciasis in theDemocratic Republic of the Congo (DRC). At the end ofour 4th year of Mectizan distribution in 2009, working with5,140 trained CDDs and 134 medical personnel, we touchedand affected the lives of 727,583 people living in 1,659onchocerciasis endemic communities, by protecting themfrom the debilitating outcomes of river blindness. UFARhas its headquarters in Lawrenceville.

To ensure the sustainability of this CDTI programme forthe projected 15 years treatment period, UFAR hasintroduced a new and innovative programme, ‘adopt-a-village’, which gives individuals or groups an opportunity toadopt villages in our project region for support, with aminimum donation of $250 per village. The funds are usedto train and retrain the CDDs in the adopted village, and toprovide them and their village chief with incentives, such asT-shirts, footballs, bicycles and radios. In return, adopteesare given framed letters of gratitude, pictures of their villagechief and/or a map depicting the village. Since the launchof the programme a year ago, 15 villages have been adopted,with donations ranging from $250 to $1,000.

Dr Daniel Shungu is Executive Director of UFAR

15 years of APOC


Partnering with APOC IEF&UFAR

By Daniel Shungu

When Merck and Company made Mectizan®available for mass distribution, IEF pioneeredthe first community-based distribution

programme in Africa in 1990 in collaboration with Africarein Adamawa Province, Nigeria. At the same time, the firstsuch community-based programme was established by IEFin Yepocapa, Guatemala at the Mexican border.Programmes followed in the Thyolo Highlands of Malawiin 1991, and Cameroon’s South Province in 1991 andAdamaoua Province in 1997.

IEF’s support in South Province hit a hiatus in the mid-1990’s but the programme maintained its level ofdistribution until IEF was asked to re-engage in 2005.Many lessons have been learned including the challenge oftreating people in areas co-endemic with oncho and Loaloa. Working closely with Cameroon’s NationalOnchocerciasis Control Programme, APOC, and the LionsSightFirst Programme in Cameroon, over 860,000 peoplein 3,522 communities in Adamaoua and South Provinceswere treated in 2010 representing 94% of all eligiblepopulations (924,650). Additionally, 7,150 Community-Directed Distributors were trained.

Data from 1997 (Adamaoua) and 2005 (South) through2010 reflect a steady increase in the number of thosetreated in both provinces with a cumulative total of5,488,518 people being treated with Mectizan over 14 years.IEF is grateful to Merck and Company, the MectizanDonation Programme, APOC, the Lions SightFirstProgram, and our many donors who supportonchocerciasis control.

We are extremely proud to be part of this historic initiative.

Pioneering Community-Based

Ivermectin Distribution in Cameroon

The International Eye Foundation, USA

United Front Against Riverblindness - UFAR

15 years of APOC


Partnering with APOC MDP

41

In 1987, Merck and Co., Inc announced the donation ofMectizan® (ivermectin MSD) for use in patients withonchocerciasis, “as much as was needed for as long as wasneeded.” Today, almost 25 years has passed and this simplestatement and the donation that followed has become thefirst and one of the biggest drug donation scale ups inhistory. The development of new strategies in health care,for which APOC has been the main driving force for the last15 years, have now led to the development of these strategiesfor control of other neglected tropical diseases (NTDs) usingmass drug administration. The exponential increase intreatments over the last ten years, the impressive results evenin conflict and post-conflict countries have been brought

about by the active and committed efforts of the membersof the APOC partnership.

The early trials with Mectizan® were conducted with theOnchocerciasis Control Programme (OCP) based in WestAfrica. Mectizan® was used extensively within some areasof OCP; but distribution of Mectizan outside of the OCParea during the first few years of the donation programmewas a result of eye care NGDOs looking to expand thebenefits of the drug to a wider population. NGDOssuccessfully expanded distribution of the drug to some ofthe worst areas of blinding onchocerciasis outside of theOCP area; however, it was clear that the majority of the 45million people thought to be infected were not being reached.Partners soon realized that the need for Mectizan in Africaexceeded NGDO resources to deliver it. The agreement to establish APOC was a major developmentto resolve these problems. As mapping technologies of REAand REMO were developed and implemented, the burdenof onchocerciasis infection throughout Africa became muchclearer and the target populations for treatment were muchbetter defined even if the numbers more than doubled!Techniques for distributing the drug in the early days included

distribution by mobile teams in the OCP countries and insome other programmes. Various levels of communityinvolvement evolved, ultimately leading to the “hallmark” ofAPOC - the Community-Directed Approach. This strategyestablished a mechanism for sustainable ivermectindistribution. Community-Directed Treatment resulted in animpressive scale up of the programme, even in difficultconflict and post conflict situations. The evidence-basedapproach and the clear programmatic guidelines and followup have resulted in an efficient and safe drug distributionsystem that has enabled Mectizan® donations to be approvedrapidly. Close collaboration among the partners, including thecommunities, has limited the occurrences of stock shortagesand other problems.

The Mectizan® Donation Program (MDP) is delighted to bea part of the APOC family. APOC has brought together theendemic communities, through their governments withprogramme implementers, funders, NGDOs as well asMDP/ Merck in a unique partnership which has madeincredible progress in the last 15 years.

15 Years of Partnership between APOC and the Mectizan® Donation Program

By Adrian Hopkins

15 years of APOC


Partnering with APOC MDP

Although MDP is guided by the Mectizan Expert Committee(MEC) which has a much wider mandate than donation tothe APOC countries, cooperation and collaboration hasalways been very productive and highly successful. MDP hasa permanent seat on theTCC, and APOC attendsthe MEC.

A perfect example ofAPOC/MDP collabora-tion is the approach todistributing Mectizan inareas where SevereAdverse Events (SAEs)have occurred related toloiasis. As a TCCmember I rememberleading a team on a jointTCC/MDP field missionto Cameroon when thepathology was stillpoorly understood. Weworked together toinvestigate possible co-factors leading to these SAEs anddeveloped the MEC/ TCC guidelines for treatment in areaswhere loiasis and onchocerciasis are co-endemic.

Following evidence that onchocerciasis could be eliminatedin certain areas of Africa, there has been an increasingemphasis on a potential paradigm shift from control toelimination in Africa. Once this had been established, MDPwas delighted to partner with APOC and the GatesFoundation to sponsor an informal consultation on

elimination in Africa which has now led to a whole newapproach in the older and better performing APOC projectswhere elimination of transmission of the disease may wellbe possible. This new approach which will involve

transmission zonesinstead of the old hyper,meso and hypo endemiczones, and may requiresome changes intreatment strategies inthe future brings acompletely new aspect tothe disease in Africa.15 years of APOC hasseen a remarkabledevelopment inonchocerciasis control inAfrica. Without APOC,MDP would havestruggled to getMectizan® out to thepeople who need it.There may still be people

in remote or difficult areas that are not getting the Mectizanthey need but for the vast majority, MDP certainly would nothave succeeded to get the medicine out there. As we moveslowly towards eliminating the disease, MDP looks forwardto the continued partnership with APOC to accomplish thetask ahead of us all.

Dr Adrian Hopkins is Director ofthe Mectizan Donation Programme

"The African Program forOnchocerciasis Control has helpedtens of millions of people fight riverblindness by enabling delivery ofMectizan in Africa. The program'sfocus in building human resourcecapacity is creating a sustainable,healthy future. Merck congratulatesthe staff, partners and supporters ofAPOC on its 15th anniversary, and welook forward to continuing ourcollaboration in the years to come."

Richard T. Clark, Chairman, Merck

A word from Merck

15 years of APOC


Partnering with APOC NGDO coordination Group

43

The NGDO Group currently comprises 18 full and associatemembers*.

The role of the NGDOCoordination Group forOnchocerciasis Control is toprovide managerial, technical andfinancial support to onchocerciasiscontrol and elimination activitiesthrough the African Programme forOnchocerciasis Control (APOC),Onchocerciasis EliminationProgramme for the Americas(OEPA) and former OnchocerciasisControl Programme (OCP)partnerships and in Yemen.

As the results of this support, theNGDO Group has assisted withmore than half a billion cumulativeivermectin treatments during thelast 20 years (1989 - 2009)distributed as follows:

• 460 million in APOC countries

• 116 million in ex-OCP countries

• 9 million in OEPA countries

• 221,999 in YemenMembers of the NGDO Group are also involved in co-implementation activities with other health interventionsincluding LF elimination programme, trachoma, malaria, soil-transmitted helminthiasis (STH) and schistosomiasis controlprogrammes, vitamin A supplementation (VAS) andcomprehensive eye care services.

As the new Chair of the NGDO Coordination Group forOnchocerciasis Control, my vision is:

• To ensure that the Group remains focused on itscore mandate especially as there is evidence of the feasibilityof onchocerciasis transmission elimination.

• To improve partnership withNTD/NGDO Network sinceNTDs are co-endemic withonchocerciasis in most of oursupported projects, and ourmembers are already supportingtheir elimination/control.

• To ensure that our advocacy as agroup continues to be effective andevidence-based in order to attractthe much needed resources andsupport from different relevantstakeholders.

• To sustain our partnership withAPOC, the supported governmentand other relevant partners in orderto strengthen health systems, avoidduplication of efforts, and ensurethat our programmes aresustainable.

• To ensure that all APOCcountries have a functional national

NGDO Coalition to support the in-country task forces foreffective programme implementation. Efforts will be intensified to find NGDO partners for someof our projects in need of partners, look for sustainable waysof addressing financial challenges faced by some of ourmembers, and seek for support for the elimination ofonchocerciasis in identified foci in Yemen.

Mrs Francisca Olamiju is Chair of the NGDO CoordinationGroup for Onchocerciasis, and Director of the NGDO

MITOSATH, Nigeria

The Vision of the new Chair of the NGDO Coordination Group for

Onchocerciasis ControlBy Franca Olamiju

* Group members: Charitable Society for Social Welfare (CSSW),Christoffel-Blindenmission (CBM),Helen Keller International (HKI), IMA World Health, Light for the World, Lions Clubs InternationalFoundation (LCIF), Malaria Consortium, Mectizan Donation Program (MDP), Mission to Save theHelpless (MITOSATH), Organisation pour la Prévention de la Cécité (OPC), Schistosomiasis ControlInitiative (SCI), Sightsavers, The Carter Center (GRBP), United Front Against Riverblindness (UFAR),US Fund for UNICEF.

Associate members: Centre for Neglected Tropical Diseases (CNTD, Liverpool), InternationalAgency for the Prevention of Blindness (IAPB), Merck Co. Inc.

A delegation from the Saudi Fund forDevelopment visited the APOCheadquarters on 11 May 2011. Thedelegation comprised Mr Hassan Alattas,Director General/technical departmentand head of delegation, Mr SaudAlfantoukh, chief engineer, and MrIbrahim Sugair, chief economist. Thepurpose of the visit was to follow up onongoing APOC projects and discussfuture cooperation between APOC andthe Saudi Fund.The Saudi Fund’s financial contributionto APOC operations has been constantsince 2004. Saudi Fund pledges anddisbursement of funds would haveamounted to more than US$ 5,000,000 by2015.The delegation commended APOC forthe impressive results on the ground,achieved with less than US$ 1 pertreatment, and declared that the SaudiFund will continue to support APOCuntil elimination of infection andinterruption of the transmission of thedisease is achieved. They furtherpromised to encourage other Arabfunding agencies to join the APOCpartnership.

15 years of APOC


Partnering with APOC

Since the early days of the fight against onchocerciasis inAfrica, WHO's Legal Office has been providing legalsupport to both the OCP and APOC programmes.

When APOC was created 15 years ago there was strongcommitment and financial support on the part of the variouspartners and donors. With so many actors and stakeholdersinvolved it was important to establish the Programme withina solid and clear legal framework. The Legal Office played asignificant role in the establishment of APOC and has sincethen, been providing regular advice on a wide range ofissues, such as the functioning of APOC's governing bodies,the status of the Programme and its operational activities atcountry level, contractual matters and a host of other things.

The Legal Office has been part of APOC’s various successesand achievements during the last 15 years, and will continueto provide legal assistance to the Programme to ensure thatits activities and operations are not delayed due to legalconcerns.On a personal note, I feel particularly privileged to work withsuch a group of highly committed professionals, be it at theAPOC Secretariat, among the co-sponsoring agencies,NGDOs or at national level. Partners come to meetingsfrom very diverse backgrounds and with differentperspectives, and what impresses me most is their ability toadopt by consensus the best decisions for the Programmeand for the African people the Programme serves.

Mr Xavier Daney is Senior Legal Officerat the World Health Organization

Visit of Saudi Fund for Development to APOC headquarters.

Providing legal Advice to APOC

APOC Director & Saudi Fund Delegation

Xavier Daney

15 years of APOC


Partnering with APOC

45

When the Onchocerciasis Control Programme(OCP) ended in 2002, it was agreed that thesuccess story and the experience should be used

for the control and surveillance of other diseases. The Multi-Disease Surveillance Centre (MDSC) was created to serve asa centre of excellence for disease surveillance in the WorldHealth Organization Africa region.

The mission of the MDSC is to provide high-level technicalsupport to member states in surveillance of onchocerciasisand priority communicable diseases in the Africa Region.

The general objective of the MDSC is to provide criticalinformation to African countries for the effectivemanagement of priority communicable diseases preventionand programmes.

Specific objectives include:

- To provide continuous entomological and epidemiologicalonchocerciasis surveillance support to countries to maintainthe achievements of OCP.- To facilitate the exchange of information and best practicesbetween countries to ensure effective prevention and controlof priority diseases- To train countries in field epidemiology and researchmethodology and to contribute to in-service training forpriority diseases to nationals in charge of surveillance- To initiate/participate in research activities leading to betterunderstanding of the major communicable and noncommunicable diseases of the region;

MDSC’s strategic directions emphasize the tracking of majorpriority diseases. Priority areas of intervention includeepidemiological surveillance; data management;entomological surveillance; laboratory support;documentation centre; training and research.

With the support of APOC, the centre gives technical andfinancial support to ex-OCP countries in implementingentomological surveillance activities. Nine of the elevencountries have collected more than 300,000 flies on a regularbasis since 2006. MDSC also carries out field entomology

training for health workers in collaboration with APOC.

Operational research activities carried out by MDSC providescientific evidence that contributes to better surveillance.MDSC, APOC and several foreign institutions havepartnered to conduct the following studies:

- Feasibility of elimination of onchocerciasis by ivermectinin Western Mali and Senegal;- Trans-border movements of Simulium damnosum fliesbetween Sierra Leone and Mali and its influence ononchocerciasis epidemiology;- Trans-border movements of Simulium damnosum fliesbetween Benin and Nigeria;- Spatial modelling of onchocerciasis using remote GIS andsensing;- Alternative methods to human bait collection of Simuliumdamnosum.- Markers for ivermectin resistance in O. volvulus

MDSC hosts the West Africa Field epidemiology andlaboratory training programme (WA-FELTP) for BurkinaFaso, Mali, Niger and Togo. WA-FELTP objectives are: 1)training leaders in applied epidemiology and public health

laboratory practice and 2) providing epidemiological andlaboratory services to national and sub-national healthauthorities in West Africa. With the financial support ofAPOC, a special session was organized on onchocerciasis).

Dr Laurent Toe is head of the onchocerciasis surveillance unit, MDSC

Partners: Ministry of Health of Ex-OPC countries ; WorldBank ; WHO/TDR : APOC ; WAHO/OOAS ; MeningitisVaccine Project ; CDC / Atlanta ; Institut Régional de SantéPublique (IRSP) Ouidah, Bénin ; CERMES, Niger; Université deOuagadougou, Burkina Faso; Centre Muraz Bobo Dioulasso,Burkina Faso; University of Alabama at Birmingham, USA;University of Tampa Florida, USA ; University of Gottingen,Germany; Noguchi Memorial Institute for Medical Research,University of Ghana at Legon, Ghana; University of Agricultureat Abeokuta, Abeokuta, Nigeria; University of Conakry, Guinea;Fondation Mérieux, Bamako, Mali; Institute Pasteur Dakar,Sénégal.

By Laurent Toe

Field training in entomology: Checking for S.damnosum larvae in river

Laboratory based entomological surveillance of vector borne diseases:International collaboration

Multi-Disease Surveillance Centre (MDSC)

15 years of APOC


Partnering with APOC PersPective

PersPective (PP) is a Bahá’í-inspired, non-profitdevelopment Association and was established with the staffof the Bahá’í Agency for Social and EconomicDevelopment (BASED) when they ceased operations.BASED was involved in River blindness control from 1998to 2004. PersPective works in the Littoral Region ofCameroon with operations in 19 Health Districts, of which11 carry out CDTI activities.

In February 2006 a technical and financial partnershipwas formed between PersPective and the Lions ClubInternational Foundation (LCIF) through itsprogramme, Sight First (SF). Since February 2010,PersPective has been involved in the fight againstNeglected Tropical Diseases (NTD) - onchocerciasis,lymphatic filariasis, soil-transmitted helminths,schistosomiasis and trachoma. PersPective’s activitiesinclude capacity building, training, health education,and gender mainstreaming.

The combined efforts of BASED (1998 - 2004) andPersPective (from 2005) have built the capacity ofgovernment health personnel and community memberswithin the existing infrastructure to sustain Mectizan®distribution and surveillance activities. Through the CDTIprogramme health personnel and community membershave been trained in supervision, sensitization andevaluation. Perspective has introduced a special programmeto improve community ownership as well as gendermainstreaming activities to sensitize the population andwomen in particular, on the important role they have to playas well as the benefits and advantages of involvement inCDTI activities. They strive to promote and increase the

participation of women at all levels of community activities,especially health and development.

From 2006 to 2010, PersPective (PP), in collaboration withthe Ministry of Public Health, has trained 926 healthpersonnel, 10,198 Community Distributors (CDDs),1,318,175 persons received 3,,899,842 tablets of Mectizan.The 2010 therapeutic coverage for Littoral I CDTI project

was 65.87% and 76.57% for Littoral II. Gendermainstreaming activities led to an increase in thenumber of women CDDs and the number of womendoing nursing and management of severe adverseeffects, women providing in-kind incentives forCDDs, and improved ownership of the CDTI projectby women.

In 2008, PersPective started facilitating theimplementation of the Community Self Monitoring(CSM) exercise in communities in the Littoral CDTIarea to help community members monitor andevaluate their Mectizan distribution system with a

view to improving project performance and ensuringsustainability.

PersPective is proud to be working in partnership withAPOC, LCIF, HKI and the Cameroon Ministry of PublicHealth in the fight to rid Africa of Onchocerciasis and otherNTDs.

Dr Mbenda BehalalGeorges

is Executive Director of PersPective, Cameroon

By Mbenda Behalal Georges

Dr Jacques Pierre Ziegler hadthe distinguished responsibilityof leading the OnchocerciasisControl Programme in WestAfrica as its pioneer Director.With a support unit at theWHO Geneva Headquarters,Dr Ziegler was installed asOCP Director inOuagadougou, Burkina Faso.

The late Dr MarcLouis Bazin fromHaïti, a formerWorld Bank andUN functionary,took over fromDr Ziegler asOCP Director

Dr Ebrahim Malick Sambawas the first African tohead OCP and wasDirector for 14 years. Heleft the OCP to becomeWHO Regional Directorfor Africa.

Dr Kofi YankumDadzie served asOCP Director andAPOC Directorfrom May 1995 toJune 1999

Dr Boakye A. Boatin wasOCP Director from 2000 to2002, when the programmeceased operation.

PAST AND PRESENT OCP & APOC DIRECTORS

Dr Jacques Pierre Ziegler

Pioneer

OCP Director - 1974-1976

Dr Marc Louis Bazin, OCP Director

1976-1980

Dr Ebrahim Malick Samba, first

African OCP Director 1980-1995

Dr Kofi Yankum Dadzie OCP &

APOC Director 1995-1999

Dr Boakye A. Boatin OCP Director

2000-2002 Dr Azodoga Seketeli: APOC Director

1999-2005

Togolese scientist DrAzodoga Seketeli wasappointed Directorof APOC fromSeptember 1999 until2005.

Dr Amazigo was appointed asthe first female Director ofAPOC in 2005, from whichshe retired on 31st March 2011

Dr Paul-Samson Lusamba-Dikassa was appointed APOCDirector on 1st April 2011

Dr Uche Amazigo: APOC Director

2005 - 2011

Dr Paul-Samson Lusamba-Dikassa

15 years of APOC


Men and woman at the helm of Oncho Control success in Africa

47

Rene Le Berre was a visionary and a man of conviction. Thanks to his pioneeringwork, the Onchocerciasis Control Programme was launched in 1974. It was one ofthe largest public health endeavours carried out by WHO, co-sponsored by theWorld Bank, UNDP and FAO. The Programme initially involved 7 countries and later extended to cover 11countries of West Africa. At the closure of the Programme in 2002, an estimated600,000 people were protected from blindness, 18 million infants born since thebeginning of the operations were no longer at risk of contracting the disease and25 million hectares of fertile land could again be used for agricultural projectscontributing to the socio-economic development of the valleys of West Africanrivers, yielding a 17% return on investment. The elimination of onchocerciasis as apublic health problem and a barrier to socio-economic development represents,with smallpox eradication, one of the great successes of WHO.

Dr Philippon’s vast contributions to the control of tropical diseases in Africa datesback to the 1960s. The renowned entomologist with specialization in vector control,bio-ecology and health research management devoted much of his professionalcareer in efforts toward mitigating the socio-economic and human devastation ofvector-borne tropical diseases on the west coast of Africa, from Mali to Côted’Ivoire, extending to the River Congo in DR Congo.Dr Philippon was part of the scientific team involved in tireless campaigns foronchocerciasis control in Côte d'Ivoire, Upper-Volta (Burkina Faso) and Mali, 1966-1971. The team established the standardized indices of measurement of blackflybiting densities and Onchocerca volvulus transmission amounts (1969) and their workled to the use of aerial spraying (larviciding) of blackfly breeding sites, the firststrategy for the control of River blindness in West Africa. Dr Philippon continues to support APOC and other disease control programmesin Africa with his expertise, scientific guidance and counselling. He is a currentmember of the APOC Technical Consultative Committee (2008-2011).

Travelling in West Africa in 1972, Robert McNamara, then President of the WorldBank, was moved by the sight of the large number of blind people in villages inBurkina Faso being led around with a stick by small children. Convinced that theresearch being carried out by French scientists at ORSTOM (the French tropicalmedicine research organization) that aimed to control the blackfly (the cause ofonchocerciasis) would work, McNamara, on return to Washington, called a meetingin Europe to meet with organizations who could possibly be interested incontributing to solving the problem of onchocerciasis in West Africa.These efforts led to the launch in 1974 of one of the world’s most successful publichealth control programmes – the Onchocerciasis Control Programme (OCP). Thesuccesses of this programme in controlling onchocerciasis through vector controlin West Africa led to the creation of the African Programme for OnchocerciasisControl (APOC) whose mandate was to eliminate the disease as a public healthproblem and a constraint to socio-economic development in the remaining onchoendemic zones outside the OCP area.

Dr Rene Le Berre died on 6th

December 2010

Dr Bernard Philippon

Dr McNamara died on 6th july

2009

PIONEERS OF RIVER BLINDNESS CONTROL IN AFRICA

15 years of APOC


Men and woman at the helm of Oncho Control success in Africa

15 years of APOC


Spotlight on APOC countries Nigeria

49

In 1997, Nigeria started receiving support from the AfricanProgramme for Onchocerciasis Control (APOC) andcommenced usage of the Community Directed Treatmentwith Ivermectin (CDTI).

NOCP/Nigeria is the largest Ivermectin distributionprogramme in the world providing over 20 million treatmentsfor the past 7 years. Over 33,000 communities are beingtreated annually, and as at 2009 a total of 35,369 communitieshad been treated. Most state projects have been achieving100% geographic coverage for the past 6 years. Nearly allstates have maintained a minimum of 65% therapeuticcoverage for the last 5 years. Overall treatments have risenfrom about 200,000 persons in 1991 to over 8 million by1997 and by 2009 had peaked at about 26 million persons.

The CDTI structure is being used to detect and refer simpleeye cases, distribute Vitamin A supplementation &insecticide-treated bed nets, and treat lymphatic filariasis andschistosomiasis in 11 of the 32 states & FCT. Capacity hasbeen built at the health service and community levels withthe training of about 20,000 health workers and 160,000community directed distributors.

Presently Nigeria has 28 projects (27 CDTI projects covering31 States and the Federal Capital Territory), as well as thenational headquarters support project.

Other achievements• Nearly 5.7 million treatments for

lymphatic filariasis carried out in 2009 using CDTIstructures

• Remote communities where normalhealth services do not reach are being covered.Such areas include the Koma people in AdamawaState and those in the riverine hinterlands ofOkwango Division in Cross River State.

• Conflict areas have been reached withthe distribution of Ivermectin

• CDD to population ratio has decreasedfrom 1 CDD to 1,395 people in 1997 to 1 CDDto 201 in 2009.

• An average of 60 million tablets are

being used for active and passive treatments annually.• Over 3,000 communities are carrying out

Community Self Monitoring (CSM) • Female involvement in decision-making and

participation in distribution of Mectizan® is rising,particularly in the southern part of Nigeria.

Elimination of onchocerciasis in NigeriaThe epidemiological assessment exercises carried out haveprovided evidence that some projects are on the path toelimination of onchocerciasis transmission in Nigeria. Theoutcome buttresses the geographic and therapeutic coveragefigures reported over the years. The results show thatKaduna, Zamfara, and Ebonyi States may have achievedelimination while Taraba and Cross River are well on theirway to elimination.

Broad PartnershipThe CDTI process in Nigeria is a broad-based partnership.Partners that have been providing support for programmeimplementation are the Government (National, State andlocal), Merck & Co. Inc., APOC, UNICEF, WHO, NGDOs,communities and local CBOs/NGOs. The NGDOs includethe Carter Center, Sightsavers, Christoffel Blindenmission(CBM), Helen Keller International (HKI), and Mission toSave the Helpless (MITOSATH).

Mr Chukwu Okonrokwo is Programme Manager/NOCP/Nigeria

Onchocerciasis Programme Milestones – Nigeria

By Chukwu Okoronkwo

15 years of APOC


Spotlight on APOC countries CAR

One of CBM’s early onchocerciasis programmes was in theCentral African Republic where we partnered with theMinistry of Health in a National Programme. Activities wereplanned in 1992 and training and distribution activities beganin 1993. The programme concentrated on the areas with thehighest prevalence.The first distribution was done by mobile teams working withcommunity leaders. The objective was to integrate theprogramme into the Primary Health Care (PHC) system byyear two. However, in many of the remote areas whereonchocerciasis was the worst, PHC was not at all functional.So, from year two, the programme became more communitybased, recruiting community leaders to fully participate in,and to a certain extent, run the programme for theircommunities. Although this process produced some goodresults it was not sustainable. With the integration of theprogramme into APOC in 1997 came more understandingof how to work with the community, using the community-directed approach. The active development of the Community-DirectedTreatment with Ivermectin (CDTI) was one factor thathelped maintain the programme during the very criticalperiods of the country’s political upheavals. Because of thecommunity ownership of the programme, if the ivermectinwas available, the communities continued to treat themselves(even when supervisors were not around to do the job)despite real political problems. In one area the communitiesinsisted on being treated since there was ivermectin availableat the sub district level, and organised some of thedistribution even though the logistics planned by theprogramme were not in place. Because of the high coverage (better than the Expanded

Programme on Immunisation - EPI - programme) UNICEFapproached the onchocerciasis programme and requestedthem to distribute Vitamin A. These activities would nothave happened if it was not for the philosophy of CDTIintroduced by APOC and the logistical and financial supportenabling the scaling up of the programme on a national scale.

Dr Adrian Hopkins is MDP Director and Mr Johan Willems is theNTD PCM officer at CBM/ Central Africa Region

CBM’s experience in Central African RepublicBy Adrian Hopkins and Mr Johan Willems

Ph

oto

cre

dit: C

BM

Ph

oto

: C

BM

15 years of APOC



51

Nigeria is the most populous country in Africa with well over140 million people, accounting for more than half of thepopulation of West Africa. The country is very rich inlanguage, culture, customs and traditions, and with 250 ethnicgroups you can imagine the fascinating diversity of thepeople and their practices. Nigeria’s literature, music, and inthe last ten years, its video-film industry are enjoyed all overthe continent and far beyond.

With 32 states in Nigeria this magazine clearly does not haveenough pages to do justice to the rich variety of the country’scultures and traditions. We will give you a glimpse byfeaturing some aspects of the Leboku Festival in Cross RiverState and the Durbar Festival in Northern Nigeria .

LEBOKU FESTIVAL

The Leboku is the annual New Yam Festival celebrated bythe Yakurr people in Ugep, northwest of Calabar. The three-week long festival held in August every year celebrates many

things: the beginning of the yam harvest, a time to appeasethe gods and ancestors and usher in peace, good health andprosperity; a public parade of engaged maidens, acommemoration of events that led to the migration from theYakurr ancestral home to the present site, and many others.

The Leboku starts with a parade across the town of womencarrying yams on their heads. There is a different event each day: a women’s festival atwhich they are given gifts by their loved ones and friends; amen’s festival when they too are given gifts; performance ofmale Ekoi dancers; Leboku maidens wearing mini wrappers,ornamental beads and leg bangles parade and dance to therhythm of the Ekoi drums.

This magazine celebrates 15 years of APOC activities, and features articles and stories that focuson oncho control, its challenges and successes on the ground.

In this section of the magazine however, we want to give our readers an insight into other aspectsof APOC countries apart from their oncho disease burden. There is so much beauty in Africa, suchrich and diverse cultures and traditions that differ not just from country to country but also withinthe same country.

We want to share some of these with you and we will “spotlight” on Nigeria and the Central AfricanRepublic.

Photo credit – calabarpress Photo credit – calabarpress

15 years of APOC



Matured maidens also dress the same way to attract would-be suitors. The brass rods shaped into leg banglesdemonstrate the extent of a maiden’s strength andperseverance – value added for the maiden and a sureattraction for suitors!!

The Mr. and Miss Leboku competition is a modern dayversion of the parade of maidens and young men. Manyhealth campaigns collaborate with the community to sharemessages during the festival.

The Durbar festival dates back hundreds of years. The first

Durbar was held in the 14th century. From each town and

district, noble families in the north were expected to

contribute a regiment to the defense of the emirate.

The Durbar is a spectacular display of horsemanship and

Hausa regional and cultural tradition and heritage. It takes

places twice a year on the occasion of the two main Islamic

feasts – Eid al-Fitr (the end of the month of fasting –

Ramadan), and Eid-al Adha (the feast of Abraham

sacrificing a lamb instead of his son), and sometimes when

high-ranking dignitaries visit the country. The entire

community participates either as horsemen or as spectators.

The highlight of the festival is when horsemen in full

traditional attire on colourfully adorned horses, amidst

singing and dancing, charge at full speed towards the Emir,

pull up abruptly in front of him, salute him with their lances

and swords before veering to the side – marking their loyalty

to their ruler.

Mr & Miss Leboku

Ph

oto

cre

dit

– c

ala

ba

rbe

ck

on

s.w

ord

pre

ss

Horsemen charging towards the traditional ruler

Photo credit: AP/Wide World Photos

DURBAR FESTIVAL

Photo credit – calabarpress

15 years of APOC



53

Broto trumpet players and dancers from Bambariin Central African Republic

The Broto trumpet players use trumpets made from treeroots hollowed out by termites. Each trumpet plays aparticular note. The ‘ensemble’ of six trumpets constitutes arange of six musical notes. Members of this group are also “lightening throwers”.Lightening is believed to be a weapon of vengeance – alizard from the village is mixed with poison and used as adetonator to ‘throw’ the lightening at the offender.

The pygmies of Central African Republic

The ‘Pygmy’ peoples of Central Africa live in rainforests indifferent countries across the region: Cameroon, CentralAfrican Republic, DRC, Rwanda, Uganda. They are stronglyconnected to the forest and see themselves as forest people.Their history, culture, religion and livelihood are all closelylinked to the forest. In their own words “they love the forestlike they love their body”. Different communities havedifferent languages and hunting traditions, and they moveoften through different parts of the forest, collectingproducts that they barter with other communities. Thispeaceful existence in the forests, however, is threatened bycommercial activities such as extensive logging, conservationparks/animal reserves.

The Mbenzele dance of the Aka pygmies in Lobaye

Music and dance are an integral part of the Central AfricanRepublic Aka pygmy rituals and are used during ceremonies,inaugurating new encampments, hunting or funerals. In factthe pygmies accompany all their daily activities with music.The “Mbenzele” dance of the Aka pygmies is for joyfulevents and dedicated to great hunters of encampments.Coming back from the hunt with big game is a reason for abig musical celebration by the entire group. The dances areaccompanied by clapping of the hands and beating of drumsand are performed by men, mixed couples or solo.

The Central African Republic lies in the centre of Africa with dense rain forests and woodedgrasslands. The country is made up of several ethnic groups, and about 49 percent of the populationlive in small villages, and follow traditional customs. French is the official language, but Sango, anAfrican language, is the also widely spoken, in addition to many other African languages. The CentralAfrican Republic, like all African countries has an abundance of customs, traditions and cultures:

Family photo after dance performance

Pygmies at home in their beloved forest

Traditional Ango-Broto trumpet players/dancers

Ph

oto

cre

dit: M

ulle

r Se

na N

atio

nal M

us

eu

m/C

AR

15 years of APOC



Aka musical instrumentsThe Aka pygmies have a variety of traditional instruments such as theflute, bow-harp, zither, sanzi and drums that they use frequently intheir music.

Peter Culshaw, in his article The Musical Pygmiesof the Central African Republic printed in The

Observer in September 2003 calls Aka pygmy music“what is most likely the oldest music in the world”. Thearticle also talks of the “the Hungarian composerGyörgy Ligeti becoming obsessed by the complex polyrhythms and irregular multi-part vocalising of thepygmies, which became a great influence on his ownwork”. And further says “Far from being primitive, themusic of the pygmies is as advanced as anything in theWestern canon”.Some years ago theAka pygmies went ona European tour,orchestrated by the classical pianistP i e r r e - L a u r e n tAimard. He released adisc that includes themusic of the Akapygmies and thepiano music of Ligeti.

Aka pygmy music canalso be found on Youtube.

Zither – 10-stringed instrument played during

festive occasions like marriages and baptisms

but also used by story tellers to capture the

attention of their audience

Vertical drums – are usually fixed and kept in the house

of the village chief and are used to get people together

for important communications , meetings or other

important events that occur in the community.

Sanzi or “thumb piano”- played at big

community festivities and traditional marriage

ceremonies. It consists of a wooden box with

bamboo or metal keys played with the thumbs.

Mbenzele traditional pygmy dance -- dancers are wearing skirts made out of tree bark

Ph

oto

cre

dit: M

ulle

r Se

na

Na

tion

al M

us

eu

m/C

AR

Ph

oto

cre

dit

: M

ull

er

Se

na

Na

tio

na

l M

us

eu

m/C

AR

Ph

oto

cre

dit: M

ulle

r Se

na

Natio

na

l Mu

se

um

/CA

R

Photo credit: Muller Sena National Museum/CAR

55

Some of the gains of oncho control

Tens of millions of children born since the start of

control efforts are free from the risk of river blindness.

An estimated 25 million hectares of arable land has been

regained for agricultural production and resettlement.

56

Documents

Concept and Production - WHO...3 My grandfather’s worldwas hard and sad.But above all it was dark. Day rolled into night and night into day. It seemed only the singing of the birds