Carter Center’s Nigeria Director Sees Challenges and Crushes Them

In many cultures, a person’s name carries significant meaning and may even be thought to describe one’s destiny. In the Southeastern region of his native Nigeria, Dr. Emmanuel Miri’s name means "water" and "life," and few names could be more appropriate for the man who directs the Carter Center's health programs in that country.

Miri has spent decades fighting river blindness, trachoma, lymphatic filariasis, schistosomiasis, and Guinea worm disease — every one of which has a connection to water.

In 1988, Nigeria was the world’s most endemic country for Guinea worm disease, reporting over 650,000 cases in all 36 states. In 2013, having worked closely with Miri’s skilled Carter Center staff and volunteers, Nigeria’s Federal Ministry of Health achieved World Health Organization certification that it had eliminated the disease nationwide.

“What I learned from the Guinea worm campaign is that these neglected tropical diseases can be eliminated,” Miri said. “We did it once, so we can do it again.”

Now Miri has his sights set on river blindness, and he’s confident of success.

“The advantage we have is that we’re coming from a background now of having been successful, and that on its own is motivating enough,” he said.  

In 2012, Nigeria bestowed its second-highest civilian honor on Miri. He’s aiming higher.

“I’ve always said that I’ve been given the Order of the Federal Republic of Nigeria; I’m looking for the top honor, the Commander of the Order of Nigeria,” he said with a laugh. “And that, I think, tells the story: That because I’ve been successful with one, I’m looking forward to more success ahead of me.”

His confidence is well founded. During his tenure, Nigeria also has stopped lymphatic filariasis transmission in two states and reduced trachoma to the point where it is no longer a public health threat.

Still, no one — least of all Miri — believes eliminating river blindness will be easy.

“One challenge that pops up straight is that now I’m dealing with a bigger number than I had with Guinea worm, because this is now quite the whole population,” whereas Guinea worm was generally a rural disease, he said. “And these flies that carry river blindness have no passport; they can fly from anywhere and get to you. So that’s one of the challenges: how to tame the black flies.”

A second challenge is the massive amount of data that must be collected to track progress against the disease. Most of the raw data will be collected by amateur volunteers, who will need extensive training and supervision.

“For example, in the Carter Center's programs, we’re talking about covering or protecting 37 million people,” Miri said. “That’s a lot of people! And we’re working in over 30,000 communities. Now in each of these communities you have two or three village volunteers, and you are generating that data from them. To compile and collate all this data to reach the right decision is one of the biggest challenges that we have.”

In addition, wherever possible, Carter Center health programs limit costs by integrating treatment for multiple diseases — river blindness, lymphatic filariasis, schistosomiasis — each with its own drug. This means volunteers must take extra care in determining and administering the correct dosage of each drug for each patient.

“The safety margin for these drugs is very good, but in the back of my mind I’m always thinking of these implications,” Miri said. “You want to be sure the man or woman distributing the drug is well equipped to do it, so we’ve increased our days for training, and this is just to avoid this kind of mistake.”

A third challenge is persuading everyone involved — the health ministry, the Center staff, the volunteers, and the population — to change their mind-set from control to elimination, he said.

“Now you need to reorient people’s paradigms and say, ‘Hey, gentlemen and ladies, business cannot be as usual; we’re now talking of elimination and not control,’” Miri explained. “Whereas with control, if someone misses treatment, it’s not a big deal. But we need now to make sure everybody takes it because it’s an elimination program. And I mean everyone: The entire population must understand, for us to get rid of this disease, we must all participate.”

The beauty of programs that rely heavily on community participation is that when the programs conclude, a trained workforce, a functional system, and an aware populace remain in place.

"We have trained people at the community level so even in our absence, something is happening. Even one health worker's visit is good enough because you have left infrastructure in the community that will carry on," Miri said. “It becomes self-sustaining.”

Miri has been in this battle for more than 20 years. He’s confident of winning, but he’d like for the battle to be over. It’s been a lot of hard work.

“I foresee that in the next five years we should be talking about interrupting transmission in Nigeria,” he said, beaming. “I think that will be great. And after that I should start thinking about retiring. So the sooner the better!”