A woman crosses a bridge over the Baro River in Gambella Town, Ethiopia. The Baro’s clean water and swift current form an ideal breeding environment for the black flies that transmit river blindness. (Photos: The Carter Center/ R. Youngblood)
Volunteer community-directed distributor Abeje Ulondimu delivers health education to Gambella Town’s Kebele 5 neighborhood during a mass drug administration event in Ethiopia.
A woman who lives in the Kebele 5 neighborhood of Gambella Town, Ethiopia, holds a dose of Mectizan tablets, distributed for the elimination of river blindness.
Most of the Carter Center’s work against neglected tropical diseases takes place in rural locations that are far from health care facilities and other resources. However, these diseases can be found in some unique urban settings, too, and the Center is just as committed to combating them there to ensure elimination is achieved.
In 2000, Ethiopia invited The Carter Center to assist in controlling onchocerciasis, a disease commonly known as river blindness. Twelve years later, Ethiopia’s Federal Ministry of Health boldly decided that merely controlling the disease ― doing just enough to keep cases from increasing ― was insufficient and instead set a goal of eliminating it altogether. The decision established Ethiopia as a leader and innovator among onchocerciasis-endemic countries.
Whereas control means committing resources indefinitely, elimination frees assets and resources to be used to fight other problems. To achieve elimination, transmission of the disease must be interrupted in low-endemic areas that are not prioritized in control programs. It also requires checking for the disease in places where it typically would not be seen, such as urban areas.
River blindness, a parasitic disease, causes intense itching and rash and can eventually lead to loss of sight. It occurs in tropical regions, mainly in Africa, with clean, rapidly flowing water where the black fly that transmits the parasite breeds. One such place is Gambella Town (pop. 62,000), the capital of Gambella region, where the Baro River rushes through on its way to South Sudan.
Originally, we did not expect to find river blindness in Gambella Town because urban rivers are usually too polluted for the black flies to breed,” said Gadisa Mohammed, the Carter Center’s deputy program director for the Gambella region. But the Baro River is actually quite clean, as well as fast, so it is suitable for the flies.
After extensive testing of the population, the program found a low level of river blindness does exist in Gambella Town, while the surrounding area is highly endemic. As a result, both the town and the area around it must be treated, said Aderajew Mohammed, program manager for the Carter Center’s health programs in Ethiopia.
When Ethiopia’s goal was control of river blindness, people in highly endemic areas were given the drug ivermectin (Mectizan®, donated by Merck & Co., Inc.) once a year via mass drug administration (MDA). Local volunteers called community-directed distributors, or CDDs, educate people, measure for the correct dose, and administer the medication. Elimination requires intensified intervention efforts: Now The Carter Center assists the Federal Ministry of Health with Mectizan treatments two times a year, four times in areas identified as hot spots.
Different settings require different approaches.
“Urban people tend to be more skeptical and more assertive about asking us challenging questions,” said Gadisa.
With support from local political officials, the health ministry and The Carter Center use posters, loudspeaker-equipped trucks, and town criers to extol the benefits of Mectizan and promote upcoming MDA events. “That strategy is very effective,” Gadisa said. “We work hard on that.”
To advance trust, CDDs are recruited from the local population. But this, too, takes extra effort.
Whereas rural people usually are farmers who can make time to assemble for MDA events during the week, “most city people are working at jobs, so it can be a challenge to find people who have flexibility to be CDDs,” Gadisa explained. This requires conducting MDA on weekends and scheduling around religious services.
So it was on a hot Sunday afternoon (before MDA activities were temporarily suspended because of the COVID-19 pandemic), a team of government health extension workers and CDDs set up tables under a large shade tree in Kebele 5, a densely populated Gambella Town neighborhood. An energetic crowd gathered to hear one of the CDDs deliver a persuasive educational message about onchocerciasis and invite them to take the free medicine to eliminate the disease. Understanding its importance to the community’s and country’s health and prosperity, the majority then eagerly lined up to receive the tablets.
“When Ethiopia eliminates river blindness, productivity will be increased, without any doubt, Gadisa said. School retention will be increased. Greater education will lead to improvement in the economy, in technology, and so on. If a person including a woman or child is ill, the family must spend its money on health care and not on other things, and that affects the economy.
Since MDA began in Gambella Town in 2016, nearly 400,000 doses of Mectizan have been administered there. In 2021 or 2022, the program intends to evaluate the impact treatment is having on transmission of the parasite. If transmission is shown to have been interrupted, MDA can safely be halted.
"Being free of disease is what we aspire to," Gadisa said.
Learn more about the Center's River Blindness Elimination Program »
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