In April 2009, Global Health Council interviewed Oladele Akogun, (bio) Nigerian parasitologist and a principal investigator in a multi-country study funded by WHO/TDR (the World Health Organization’s Special Programme for Tropical Disease Research.)
The focus of Dr. Akogun’s research was community directed intervention (CDI) a strategy for the delivery of health interventions selected by community members to address the diseases that most affect them. The community collectively plans how, when, where and by whom the interventions will be distributed, working in conjunction with local health facilities and government.
In June 2008, Oladele presented the results of this CDI research at a GHC event on Capitol Hill, following a presentation on CDI by WHO/TDR’s Jane Kengeya Keyondo (bio) at GHC’s 2008 annual Research Symposium in May.
This interview is divided into two parts. In Part One, Dr. Akogun highlights progress in combating tropical diseases, using the CDI approach and its acceptance by policymakers. He also looks at other related issues such as the future of primary health care and prospects for financial support of this neglected area of research.
Global Health Council: How successful are the efforts to control tropical diseases such as onchocerciasis and filariasis?
Dr. Akogun: We are doing pretty well with community-directed interventions (CDI) and can feel proud to be part of the huge team in this enterprise. There is hardly an onchocerciasis-endemic community in Africa (outside of conflict areas) that does not have a trained health commodity provider, ivermectin, vitamins, insecticide treated nets or antimalarial drugs.
The fly vectors for onchocerciasis remain, but we should focus on the worm that causes us harm, not the fly that serves as nuisance and accessory, lest we create fresh ecological problems for our much over used earth.
At the current rate of progress, onchocerciasis will be buried by the year 2015 and students at that time will only read about it in old text books.
Filariasis will likely suffer the same fate as onchocerciasis. The mummified forms of the worm will be available for those interested in history of disease control from about 2025. There is no gainsaying this, given the level of global interest and TDR’s role in ensuring that research leads the action.
Global Health Council: The CDI strategy for multiple diseases grew out of successes with community-directed treatment for onchocerciasis. How did you, others at the African Programme for Onchocerciasis Control and WHO/TDR take what worked for one disease and make it work for several?
Dr. Akogun: Adaptation is the word. I am lucky because I entered graduate studies just as ivermectin was being applied for human use. Otherwise, I would have been in some laboratory looking at the cuticle of the onchocercal worm for my doctoral research, or studying the courtship dance of filarial worms.
Global Health Council: Does CDI work the same for all diseases?
Some diseases are easier to address than others. For example because the community perceived malaria and onchocerciasis as common concerns they were willing to address them. However, we ran into a problem attempting to manage morbidity due to lymphatic filariasis because the community perceived it, not as a common problem, but as a deserved punishment for past transgression. Why then would any community be willing to apply its resources to such a health problem? Continuous education and training of community directed distributors can help to change the community’s attitude.
Global Health Council: How does CDI fit in with the Bamako Initiative for health services for all?
Dr. Akogun: The Bamako Initiative of making health service accessible to all has a will, but lacks the tools to implement it. Every district of every African country has some kind of health facility, most of which face a myriad of barriers. CDI removes all these barriers by bonding the health facility to the community. That is the treasure we found.
I am convinced that CDI can be a tool for implementing primary health care. In fact, I fail to identify any primary health service it cannot deliver. The approach is grass roots-based with components for initiating, implementing, reviewing, demanding and evaluating interventions.
Still in its infancy, CDI, like epidemiology, will grow to become a major discipline in public health. Until that happens, primary health care implementation will continue to be a goal without direction.
Global Health Council: Is anyone researching how to expand primary health care through the CDI approach?
Dr. Akogun: Yes. It is heartening that WHO is examining this possibility. The research at TDR on the application of CDI to primary health care will help us to advance the discipline further. We might even call it Participatology.
The challenge is that these are complex and difficult studies, which unfortunately attract few investors. This will prove to be a regrettable mistake. Knowledge from the West will continue to be frustrated in the field until we know how to better apply it in non-Western settings. WHO has been doing that with African partners and it is paying off handsomely.
Global Health Council: Are any other groups working to expand CDI?
Dr. Akogun: The African Programme for Onchocerciasis Control (APOC) is looking at how the African health schools can include it in their curriculum and I am collaborating with the Common Heritage Foundation in Nigeria and the Parasitology and Public Health Society of Nigeria to actually develop the model further.
Our creativity is all that is required. Development experts attempting to improve community health without the community participation that is central to CDI is like a barber attempting to give one a haircut in one’s absence.
Global Health Council: What financial support is there for CDI expansion?
Dr. Akogun: Aside from TDR, I don’t know of any other funding agency that supports this type of research.
In my University, TDR-funded research accounts for 75% of all our research funds and 100% for all our health-related research. I would like to see the United States’ NIH fund CDI strategies that take their other research products and result in a desired outcome in an African community. It is not enough to develop a vaccine; it is more important to develop a strategy for its use by the target community.
America focuses too much on the weapon of war against parasites and disease agents and not enough on the combat strategy – and any general will tell you that approach won’t win a war. I think the changes in the global war on terrorism that are refocusing on strategy (not new weapons) should be extended to the terror and anguish caused by parasites and tropical diseases.
Global Health Council: Has your success with CDI research in Africa encouraged support from African policymakers?
Dr. Akogun: I don’t think any health commodity has ever been so well received by policymakers, as the CDI strategy. The initial hesitancy was good for everyone – policymakers insisted that researchers show convincing evidence of effectiveness. Now they are ahead of the research community in their embrace of CDI. And the enthusiasm is infectious. CDI was the take home song at the April meeting of health ministers in Ouagadougou last year. In Nigeria, it is the ‘open sesame,’ or ‘magic wand’ for equitable distribution of health commodities – whether for interventions against malaria, worms or malnutrition.
Global Health Council: What is the Nigerian Ministry of Health doing?
Dr. Akogun: The Federal Ministry of Health has witnessed a lot of changes since 1999, which calls for celebration. It is an action-packed ministry with a list of priority research topics, but unfortunately the States aren’t so active, except perhaps Lagos State. Many merely adopt the federal list without assessing the local relevance. They are not as creative as the federal level, where, professional competence and leadership has been the mainstay for the past 10 years.
Yet the hub of implementation is at the State level and I would like to see the States set their priorities. Malaria will be top on every State list. Next priorities will be the worms –intestinal ones, the filarial worms. If we can tackle these in the next 10 years, we will only need to continue with surveillance of other diseases, like the human African trypanosomiasis in the guinea savanna areas of Nasarawa, Plateau, Taraba and Bauchi States.
I am optimistic that with the initiative APOC has shown in supporting multiple disease intervention in a few States, we can rid Nigeria of this annoying state of infectious diseases. But there is the health system that must be reformed at the local and State level. They can surely do much more than they are doing at the moment. Whatever list they make, the community should be the guide. The community is the smallest unit of implementation and evaluation and their needs should determine the national priorities.
Global Health Council: Do you see CDI being adopted more widely by other countries?
Dr. Akogun: I see every country adopting the strategy in time to come. CDI is the most resource-efficient means of delivering multiple health interventions. It assures nearly universal access to all services and commodities; only the community itself can remove any service from the conveyor belt. CDI is based on community empowerment; empowerment creates demand; demand leads to dialogue and information sharing; which in turn brings understanding and innovation.
World Health Organization. 2008. Community-directed interventions for major health problems in Africa. Available from: http://www.who.int/tdr/publications/publications/cdi_report_08.htm
Akogun OB, Akogun M, Audu Z. 2000. Community-perceived benefits of ivermectin treatment in northeastern Nigeria. Social Science & Medicine 50:1451-56.
Akogun O, Audu Z, Weiss M, Adelakun A, Akoh J, Akogun M, et al. 2001. Community-directed treatment of onchocerciasis with ivermectin in Takum, Nigeria. Tropical Medicine and International Health 6 (3):232-43.
Kelly MG, Akogun OB. 1997. Rapid assessment of onchocerciasis prevalence and a model for selecting communities for ivermectin distribution in West Africa. Zbl Bakt 286:146-54.