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Response and viewpoint
Posted by plosmedicine on 30 Jul 2010 at 22:09 GMT
Posted by PLoS Medicine on behalf of:
Uche V Amazigo and Stephen Leak.
African Programme for Onchocerciasis Control (APOC), Ouagadougou, Burkina Faso
The social aspects related to NTD control as emphasised by Spiegel and colleagues  are indeed very important. Our viewpoint in regard to this debate is based on 15 years of experience of the African Programme for Onchocerciasis Control (APOC) working with communities for the control of Onchocerciasis. During this period, the Programme has engaged over 120,000 communities, predominantly in remote areas of 19 African countries. Through the efforts of a cumulative total of over 700,000 community selected and trained drug distributors, under community direction, over 57 million people were treated with ivermectin in 2009 in 108 Community Directed Treatment with Ivermectin (CDTI) projects. Community ownership of these projects is a key element of the programmes sustained success and empowered them to determine the period and mode of annual treatment.
The successful engagement of communities, which APOC considers to be a pre-requisite to sustainability of control of diseases in remote rural areas, where they are most prevalent, depends upon understanding of communities' priorities and perceptions of health service delivery. The aspect of power relations between community members and health professionals must also be well understood and addressed through health promotion, education and sensitisation, directed at all levels. Community members need the power to make decisions and participate in administering their own health care where applicable and health professionals should be willing to transfer the power that they traditionally had to communities. If sustainability of the control of Neglected Tropical Diseases (NTDs) is viewed by donor agencies and health providers as an important element for elimination, then making control programmes people-centred should not mean thinking for the poor, but rather giving the poor the authority to make decisions. This movement from the medical model of disease management towards a social model requires careful handling as long-held views do not change rapidly, as seen in other areas of health management in both developed and less developed countries.
Likewise, the view that prevention of disease through environmental change should be undertaken alongside prevention or cure through therapeutic means is clearly relevant for diseases such as schistosomiasis, trachoma [2-4] and malaria . For diseases such as onchocerciasis and trypanosomiasis, control by environmental means is a less relevant option. Whilst there are environmental risk factors such as living in proximity to breeding areas of the vectors or engaging in occupations that bring people in closer contact with the vectors; these risk factors are less susceptible to management without having adverse socio-economic consequences. Agricultural practices have been associated with malaria transmission, suggesting possibilities for changes that could be made to reduce transmission although this would still need to be done in conjunction with treatment and other preventive measures . Spiegel et al.,  suggest that drug development detracts and diverts attention from, among other, mobilisation to apply measures....”such as community-based vector control”; whilst making a valid point about the value of environmental hygiene as a means of reducing the NTD disease burden. We argue that a sustainable and cost-effective method for alleviating the burden of diseases amongst the poor would involve purposively allocating up to 15% of NTD funding for engaging and educating people on environmental hygiene for STH, schistosomiasis and trachoma control programmes and the need for adhering to treatment for the control of onchocerciasis and LF. Environmental hygiene measures can only succeed if community members understand and accept that a change in their practices is the only means of breaking the devastating cycle of transmission for STH, schistosomiasis and trachoma such as constructing and using latrines. It is for these reasons that we argue in favour of education and sensitisation of target groups at community level as well as for front line health personnel.
From primary to University education, teachers invest time and resources simply and tolerantly explaining to and teaching students including future medical doctors and policy makers. This approach can only have limited success unless this investment in education is matched by education and sensitisation of the ‘bottom billion’ harbouring the greatest burden of the NTDs. Such an investment would enable them to understand the preventive aspects of disease control and would allow them to make a significant contribution to the fight against these diseases. The challenge is, we think, to engage the bottom billion. At present they are neither encouraged to think for themselves nor to suggest strategies for control; they have for decades remained unrecognised as effective partners in finding solutions to their health problems. This is the ‘true’ debate we need in order to be able to address the needs of the poorest of the earth and to develop appropriate indicators for measuring the future impact of pro-poor interventions.
A different approach to community participation is required for some NTDs, such as trypanosomiasis as, whilst considerable efforts have been made at community-based vector control  these have generally proved unsustainable with only limited success in reducing outbreaks of human sleeping sickness. Reasons for this are complex and include the technical inputs required for successful control, and difficulties in sustaining community efforts for a public rather than a private good. However, we agree that a key to successful and sustainable control is community ownership, whether of MDA projects or environmental hygiene in the context of insufficient resources.
Regarding the viewpoint of Hotez et al.,  there is a very clear and valid argument for urgently making the drugs for prevention of the curable or preventable NTDs available to affected populations. This is especially so as there are now safe, effective and relatively cheap therapeutic drugs for five of the commonest NTDs, which, as Hotez et al. rightly say, affect more than a billion of the World’s poorest and most underserved people. These drugs undoubtedly save lives and reduce suffering and should continue to have a place in integrated NTD control programmes . For some neglected diseases the unavailability of drugs has been a major concern, for example, few new drugs have been developed for treatment of human sleeping sickness because of the absence of a commercial interest for pharmaceutical companies for a disease affecting predominantly poor rural communities of Africa. For many years treatment relied upon toxic drugs with severe side effects. The few new drugs available for treatment of human sleeping sickness are too expensive for general use. Without the generosity of manufacturers and donors the cost of some of the drugs for the 5 main NTDs would be an obstacle for their sustained widespread use in most developing countries.
Given their availability it would be unethical to continue the neglect and deprive millions of people of them due to their poverty and inaccessibility; rather there is a duty to meet the challenge of delivering the drugs to them in a sustainable way despite the many obstacles. Whilst Spiegel et al.,  rightly argue that a dependence upon drug use will not be a long-term solution for NTD control where there is a cycle of reinfection; it can be a means of eliminating onchocerciasis under specific epidemiological conditions . This emphasises the necessity to distinguish between those NTDs (onchocerciasis, LF) that are transmitted by vectors from those which are predominantly transmitted under conditions of poor personal hygiene. Poor personal or communal hygiene does not make a person vulnerable to the bites of blackfly or tsetse fly vectors but rather increases vulnerability to trachoma and STH infections.
Our view is therefore to suggest a more integrated approach encompassing some aspects of each of the three viewpoints and this is, indeed the methodology used successfully by APOC for over 12 years. APOCs strategy is to engage and empower communities, in such a way that they can take responsibility for appropriate aspects in managing their health. Health promotion and sensitisation forms a significant part of the activities of the programme and of course depends upon communities to administer treatments. Due to the nature of onchocerciasis, there has been less emphasis on prevention of the disease through environmental management. Before the advent of onchocerciasis control programmes people in affected areas managed risk by abandoning affected areas and whilst this could be effective in terms of moving away from locations where they could become infected, it had serious socio-economic consequences as it took away livelihoods and meant that much fertile land went unused on a continent for which agricultural productivity has not kept pace with population growth.
The challenge faced by health policy makers is to devise sustainable people-centred strategies, to integrate the three approaches involving social determinants, preventive means and drug distribution. As the financial resources that the proponents of the three viewpoints compete for are limited, a logical approach is to integrate programmes for NTD control so that these resources can be shared and the benefits maximised. Whilst allocating 15% of NTD funds, as argued by Spiegel et al.,  to ‘disease reducing interventions’ we strongly argue that this fund should be used for strengthening primary health care services including a strong component for education of and engaging the affected populations or communities . This requires good coordination and sometimes a change of organisational and ODA culture accompanied by a willingness to modify power relations. Such integration of interventions proved successful in disease prevalence reduction in Madagascar .
In conclusion, we support the use of MDA schemes with strong education component for NTD control and agree with Spiegel et al.’s  suggestion of a social offset as health system strengthening is also an essential element of MDA through the community-directed interventions (CDI) strategy such as that adopted by APOC partners in 1997. A proportion of the 15% social offset suggested by Spiegel et al.,  should be used for education, not only of front line health workers, but equally, if not more importantly, for education and engagement of target populations without whose active participation NTD control is not achievable.
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