Bringing NTDs into sharp focus: A joint vision for better sight in Ethiopia

By Sibylle Koenig 16 November 2015

In an effort to determine the extent of trachoma, field teams visited remote and rural areas across the country, examining people in the community and recording cases of trachoma. Photo by: RTI International

As the late American author, political activist and lecturer Helen Keller once said, “The only thing worse than being blind is having sight but no vision.”

In pursuit of a vision, the first step is to see the key problems to be addressed. But astonishingly, the international community has all too often remained “blind” to one of its intractable challenges — the so-called neglected tropical diseases.

Neglected they may be, but the numbers are far from negligible. According to the World Health Organization, NTDs blight the lives of about 1 billion — or 1 in 7 — people on the planet.

The figures are staggering, so just why are these diseases “neglected”?

Devex got the inside track on the issue in a series of exclusive interviews with some of the partners working on the frontlines of NTD control and elimination efforts in Ethiopia.

Why are NTDs neglected?

“It’s a good question, but the answer is sadly very simple,” said Angela Weaver, senior technical advisor for the U.S. Agency for International Development’s NTD program. “They are diseases of poverty — not only do they mainly affect the poorest within developing societies, but they also keep people in poverty as they impair them from engaging in a productive life.”

NTDs coexist with poverty, Weaver said, because they thrive in areas where access to clean water and sanitation is limited, and people live without protection from disease vectors.

Fortunately, there is light at the end of the tunnel.

What is ENVISION?

ENVISION is an eight-year project funded by USAID aimed at providing assistance to NTD control programs for the control and elimination of seven targeted NTDs: lymphatic filariasis, onchocerciasis, schistosomiasis, three soil-transmitted helminths (roundworm, hookworm, whipworm) and trachoma. ENVISION currently provides assistance to 19 NTD endemic countries in Africa, Asia and Latin America. Nearly half a billion treatments have been provided to people at risk for NTDs with project support. Read more here.

According to several experts interviewed by Devex, seven of the most prevalent NTDs can be controlled or eliminated in the not-too-distant future by using basic public health strategies, including mass drug administration, as well as ensuring access to clean water and sanitation.

“It is relatively easy to control these NTDs, so we have a moral imperative to do it,” said Michael French from the Schistosomiasis Control Initiative.

Following this line of thinking, through its 2012 London declaration on NTDs, the international community agreed on an official road map to put an end to NTDs by 2020.

Private sector partnership

The international pharmaceutical sector has been a key player in this deal, committing to expand existing drug donation programs to meet demand through 2020.

“NTDs is the area involving arguably the largest public-private partnership in the health sector worldwide,” including companies such as Pfizer, GlaxoSmithKline, Johnson & Johnson, and Merck & Co., according to Lisa Rotondo, project director for ENVISION, USAID’s largest NTD project, led by RTI International.

Today in Ethiopia, for example, international partners celebrated Pfizer’s donation of the 500 millionth dose of Zithromax (azithromycin) tablets — an antibiotic used to treat trachoma, a severe eye infection and the world’s leading infectious cause of blindness.

According to Rotondo, the antibiotic has been used to treat more than 100 million people worldwide. Weaver added that the reach and success of USAID's efforts in trachoma under the NTD program would not have been possible without such a tremendous commitment from Pfizer.

Indeed, such commitments seemingly outweigh commercial interests for pharmaceutical partners involved. Asked about Pfizer’s motivation for the initiative, representatives Darren Back, senior director, corporate responsibility and Julie Jenson, director, corporate responsibility explained that the company sees its partnerships as an integral part of its public health responsibility.

According to Alison Hill, global lead communications officer from the Fred Hollows Foundation, however, eliminating a disease such as trachoma requires going beyond mass drug administration by taking a more comprehensive approach.

Fighting trachoma in Ethiopia

As a country blighted with the highest burden of trachoma in sub-Saharan Africa, Ethiopia was also blessed with arguably the clearest vision on how to effect change beginning in the late 1990s. In 2013, the Ethiopian government further invested in the launch of its “National master plan for neglected tropical diseases 2013-2015,” including a plan to scale up the SAFE strategy — surgery, antibiotic distribution, face washing and personal hygiene, and environmental improvement — to eliminate blinding trachoma by 2020.

Two years into the implementation of the strategy, Ethiopia has made “incredible progress,” according to ENVISION representatives, thanks to concerted efforts made by international and national partners to-date.

Scott McPherson, RTI’s chief of party of NTD programs in Ethiopia, said the joint initiative had already resulted in “86 percent coverage of endemic districts under the [surgery] and [antibiotic distribution] components of the strategy, with more than 59 million treatments planned in 2016 alone.”

And there was broad agreement that addressing trachoma in a country of the size and demographic distribution of Ethiopia was certainly not a “walkover” — not least, explained RTI’s Rotondo, because ”the most affected population groups are typically also the most remote and marginalized ones.”

The recipe for success

There are several key ingredients, said ENVISION partners, which have helped Ethiopia mobilize support for its NTD program: “Firm political will and leadership of Ethiopia’s Federal Ministry of Health and the partnerships created by national and international actors to align and coordinate their actions under that lead were the first two factors,” said Kelly Callahan, director of the Trachoma Control Program at The Carter Center, an organization that partnered with the ministry to launch its initial trachoma control program in 1999.

A sign of progress in Ethiopia.

A prime example of this leadership is the Minister of Health’s initiative to address all trachoma-related surgeries in the country via a challenge grant to partners, in which the MoH pledged $500,000 to assist with the cost of training surgeons.

Essential to ensuring a truly comprehensive approach for trachoma, USAID’s Weaver continued, is “the government’s policy on requiring full implementation of the SAFE strategy. This has required innovative partnering among donors and NGOs to ensure that all — and not just one — of the components of the SAFE strategy are implemented.”

Having the benefit of a strong national task force and the coordinating leadership of the MoH enables everyone to coordinate and cobble together greater overall coverage of NTDs. This has resulted in not only the massive expansion of the SAFE strategy for trachoma, but also sufficient support to address 100 percent of the MDA needs for soil transmitted helminths, schistosomiasis and lymphatic filariasis in the country.

Accordingly, the flexibility and willingness of donors to fill gaps where needed “instead of doing things according to their own funding guidelines” was equally as crucial, said the Schistosomiasis Control Initiative’s French. While the ENVISION project initially focused on MDA, for example, USAID’s complementary support to MMDP — morbidity, management and disability prevention — allowed the program in Ethiopia to expand the scope of its activities towards including the necessary surgical interventions.

Last but not least, explained the Carter Center’s Callahan, was the training and strategic deployment of the MoH’s health extension workers “army,” which has been “instrumental” for reaching the most remote populations in the country, in addition to working with Lions Clubs volunteers.

Remaining ‘blind spots’

There are clearly many remaining challenges to be addressed before reaching the 2020 elimination target, Devex has learned. According to Biruck Kebede, current NTD case team leader at Ethiopia’s MoH, considerable additional resources and efforts will be needed to ensure full SAFE strategy coverage in the country. While good progress had been made on the surgery and antibiotic distribution components, more focus needs to be put on face washing and personal hygiene, and environmental improvement in the coming years.

To that end, integration of the SAFE strategy principles with other NTD programs, as well as within water, sanitation and hygiene — or WASH — strategies will be crucial, said Kebede.

RTI’s McPherson concurred, giving the example of the ONE Wash sectorwide approach launched in Ethiopia in 2013, which involves an extensive network of WASH organizations working in 70 percent of trachoma endemic districts in the country. “A WASH program may be drilling wells and building latrines unknowingly in a trachoma-endemic district without including messages on trachoma prevention, which is a huge lost opportunity.”

While trachoma-related messages are not yet communicated within many WASH programs, messages are being integrated in the Amhara region. One solution or application for other parts of the countries could be as simple as incorporating behaviour change messaging, he said,  to encourage people not only to wash their hands, but to wash their faces too.

The next step is therefore to encourage WASH organizations to incorporate NTD-related messages into their work. As explained by the Fred Hollows Foundation’s Alison Hill, “involving civil society — in its entirety — is essential to get these messages across to the most remote communities.”

The Ethiopian MoH’s Kebede added that, in addition to learning about MDA, it was equally important that health extension workers were trained on how to implement the WASH principles. An integrated approach, he said, would require relevant government ministries in charge of water, health, agriculture, education and finance to agree to work together towards one objective.

This feature-length documentary follows Carter Center staff and global health partners in the fight to eliminate blinding trachoma in Ethiopia. Produced by Cielo Productions and directed by Gary Strieker.

Looking ahead

The good news is that all partners are ready to take that vision to the next level: Ethiopia’s MoH has put in place a strong “NTD action” team to take the work forward and donors like USAID have recently agreed to extend their support to the ENVISION project until 2019.

However, in a country of the size and scale of Ethiopia there can never be too much support and the call to action from the MoH and ENVISION partners to the global development community is loud and clear: join the fight against NTDs and fill in the gaps wherever needed to reach the 2020 goals.

The call is just as relevant beyond Ethiopia’s borders: ENVISION is currently working in 19 countries, with great variations in progress between them. The key task ahead is to replicate the Ethiopian success story: “Everything that has happened in Ethiopia is replicable elsewhere — provided there is the political will, stakeholder commitment and coordination, and the resources,” said RTI’s Rotondo.

Political will, she said, is not only needed at the national level, but also at the global level. A first step in that direction has already been made through the inclusion of the NTD-specific target 3.3 in the new Sustainable Development Goals framework. Said Rotondo: “What is crucial now is that the target translates into measurable indicators.”

The world will be watching, with many pairs of eyes in countries across the globe collectively looking ahead towards a brighter future.

ENVISION is implemented by RTI International in partnership with CBM International, The Carter Center, Fred Hollows Foundation, Helen Keller International, IMA World Health, Light for the World, Sightsavers, and World Vision. Follow us on Twitter and Facebook.

About the author

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Sibylle Koenig

Sibylle Koenig is a development consultant and policy adviser with 10 years of experience in managing, monitoring and evaluating international aid programs and grant schemes, as well as advocacy. She has worked for a variety of organizations, including the European Commission, U.N. and bilateral aid agencies and NGOs in Latin America (4 years) and Europe, with extensive work travel to Africa (Tanzania, Uganda, Mozambique, Kenya, Botswana) and Asia (Cambodia, Vietnam, Thailand, India, South Korea).


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