Director’s Report – A Decade of Service

DIRECTOR’S REPORT
HEALTH AND DEVELOPMENT INTERNATIONAL
- HDI -
A DECADE OF SERVICE
IN THE WORLD OF PUBLIC HEALTH AND DEVELOPMENT

REPORT TO TRUSTEES AND INTERESTED PARTIES

10 June 1999

INTRODUCTION

HDI continues to make significant contributions in the areas of guinea worm eradication and lymphatic filariasis elimination, both in specific countries and at the international level.

Earlier this year, we successfully hosted a drug distribution workshop in Annecy, France at the Fondation Meriuex’s beautifully lakeside conference center, where Merck, SmithKline Beecham, WHO, the World Bank, current and former Ministry of Health people from Asia and Africa, as well as scientists and public health professionals hammered out some pretty tough, formerly somewhat contentious issues.

Based on what was achieved in Annecy, it should now be possible to move forward with plans in individual countries, to distribute drugs in annual mass-treatment of affected populations.

Also, the brochure which we produced in close collaboration with WHO has received rave reviews.

Most recently of all, we managed to solicit support of over $500, 000 for field activities aimed at helping seven West-African countries interrupt guinea worm transmission by the end of the coming year. And we successfully assisted in the mobilization of 7.5 million Norwegian kroner (almost $1 million) from Norway’s government to the World Bank Trust Fund for guinea worm eradication, for which The Carter Center is the executing agency.

The need to be on top of administrative details which arise from the new country support for guinea worm eradication and our support for Ghana and Togo in lymphatic filariasis, efficiently yet as inexpensively as possible, now looms as our greatest challenge.

OUR SECOND DECADE – THE WAY FORWARD

Our current President, Dr. Jacquie Kay, succinctly formulated HDI’s key approach:

We are “putting our finger in the dike” as threatening leaks are discovered, in critical places where our modest size allows a quick response.

We have thus been able to have an impact well beyond what might be expected when viewing the size of our budget and personnel. It seems fair to say that HDI has been able to make a major difference during our first decade of operation, both toward eradicating guinea worm disease and to the budding lymphatic filariasis elimination program.

Our goal for the coming decade is to continue doing what we have been able to do successfully so far.

HDI plans to continue stepping forward when we see opportunities, to significantly benefit the health and development possibilities of people who experience suffering and degradation in ways which seem easily preventable but are relatively ignored at the time we become engaged in the effort. For now, we will continue concentrating on guinea worm eradication and lymphatic filariasis elimination.

Organizationally, we have had the extraordinary good fortune of being housed in the offices of two trustees, first that of George M. Hughes, and then that of Jacquie L. Kay. It seems time to continue gently growing the organization in tune with our expanding activities, while keeping the administrative side of things as lean as at all possible.

How this can best be done will be a topic for ongoing consideration by the trustees. It seems unwise in the long run, as a matter of principle, to rely on board members to provide the organization with a “home-base secretariat” in the States, generous though our two trustees have been in doing so from HDI’s inception. I think we have grown to the point where HDI can justify establish a more professional administrative arrangement.

HDI’s board of trustees has evolved in breadth during our first decade. As we now approach our second, we will want to continue carefully considering the composition of the board and possible expansions. For one thing, there is still only one woman on the board, clearly too few. Also, we are under-represented in terms of fundraising expertise and strength, and all of our board members so far have had their origins in developed countries of the world – basically the USA and Norway.

Another topic for consideration as we enter our second decade, is whether the trustees may prefer to establish a fixed number of years as the normal term for service on the board, with the possibility for re-election at the end of a term. We have received an indication that some feel this may be preferable to the current situation.

OUR MOST RECENT YEAR

LYMPHATIC FILARIASIS / ELEPHANTIASIS

- AT A GLOBAL LEVEL

The Annecy Drug Distribution Workshop

February 24-26 1999, HDI convened a workshop on “Effective and Efficient Drug Distribution for the Elimination of Lymphatic Filariasis”. Held at the conference center of Fondation Meriuex, a WHO Collaborating Center in Annecy, France, an hour south of Geneva, this was a logical follow-up to the Global Policy Retreat we co-sponsored on Magnetic Island in Australia during July of 1997.

The Annecy workshop’s 31 participants included the Deputy Minister of Health from Ghana, the former Minister of Health from the Philippines, the World Bank, WHO, The Carter Center, Centers for Disease Control and Prevention (CDC), Merck, SmithKline Beecham, several non-governmental organizations including Physicians Without Borders (MSF), and public health specialists and scientists from Brazil, Ghana, Nigeria, Tanzania, and Togo.

The “leg work” in preparing for Annecy was done on a pro bono basis by our President and Executive Director, Drs. Jacquie Kay and Anders Seim, as well as by Mr. Scott Buquor in Jacquie Kay’s office. HDI’s three representatives served as the secretariat for the meeting, which was largely chaired by our President, and our Executive Director.

Leading up to Annecy, the 1997 Magnetic Island Policy Retreat in Australia was initiated and co-sponsored by HDI. The Policy Retreat specified types of partners which will be necessary for lymphatic filariasis elimination to succeed, and other key issues to be addressed. Participants included scientists, public health policy academicians, ministry of health personnel from Africa and Asia, and senior WHO staff, as well as representatives from non-pharmaceutical industry and non-governmental agencies.

Major issues identified at the Policy Retreat include the need for national programs to incorporate alleviation of the suffering caused by filariasis, as a key pillar alongside efforts to interrupt disease transmission. Also highlighted were the need for more detailed socio-economic analysis of damage caused by filariasis, benefits of its elimination. Concerns about advocacy and the challenges filariasis poses, were key to many of the Magnetic Island discussions.

An important follow-on step after Magnetic Island was the subsequent SmithKline Beecham-WHO Partners Forum, held in Geneva, October 28-30, 1998. HDI was represented by both our President, Dr. Jacquie L. Kay, and our Executive Director, Dr. Anders R. Seim. Similarly, the Centers for Disease Control and Prevention (CDC) held a meeting of epidemiologists in Atlanta in 1998, to discuss key issues relating to reliably measuring progress made by national programs.

Also subsequent to recommendations made at the Policy Retreat, came establishment of the “Economics of Lymphatic Filariasis Project” at Emory University in Atlanta, Georgia, USA. The Economics Project aims to quantify the costs of lymphatic filariasis to patients and the societies in which they live, as well as performing cost-benefit, cost-effectiveness and decision analyses for the Global Programme to Eliminate Lymphatic Filariasis.

In Annecy, we got down to nuts and bolts in a very concrete way, as they have done in Atlanta. How do we distribute drugs from two very different and sometimes competing manufacturers, to millions and millions of people in remote rural and urban corners of developing countries, in ways which avoid pilferage or damage to supplies, and which make both drugs simultaneously available to each individual, reaching over 85% of the treated populations? How do we do this in intimate collaboration with the regular health care services (where such services exist); how do we do it in areas where other health care services are very weak or essentially non-existent; how do we ensure complementarity and co-ordination with other major mass-treatment programs, such as those against river blindness and intestinal worms?

The annual distribution of drugs and symptom alleviation supplies (mainly soap, antimicrobial ointments and some bandaging materials), will be a major pillar of every national filariasis elimination program. Approaches hammered out in Annecy will help resolve issues which could have become contentious, and they should have a direct, very positive impact on the ability of national lymphatic elimination programs to succeed.

The Annecy workshop has already been characterized as one of the key events in lymphatic filariasis elimination. For HDI, putting on such a meeting was a major undertaking. We are of course pleased by the highly positive feed-back.

HDI’s Lymphatic Filariasis Brochure

After a long gestation period, a penultimate version of our lymphatic filariasis brochure was printed in time for the Geneva Partners Forum in October 1998. Comments and refinements were incorporated, and a larger print run of 1,000 copies was ready for the above mentioned Annecy workshop.

The brochure has received rave reviews and was distributed by the World Bank to overseas staff during its week of internal meetings called Human Development Week, in March 1999.

WHO, which has lent its logo to the final version, has similarly used the brochure during international meetings.

LYMPHATIC FILARIASIS / ELEPHANTIASIS continued

- AT THE COUNTRY LEVEL

Supporting Filariasis Elimination in Ghana and Togo

GHANA

Because Ghana was ready to provide mass-treatment to the population of a pilot area while the donation program for albendazole was not yet operational, HDI purchased albendazole from SmithKline Beecham to allow Ghana’s program to move forward.

We and the government of Ghana felt it important to capitalize on the enthusiasm of the population which had already been mobilized and provide treatment to villagers who had already cooperated in scientific studies on this disease. In addition to medication, we provided test-kits to help evaluate the impact of program activities in this pilot area.

TOGO

In the past year, HDI supported the initial national survey for lymphatic filariasis in Ghana’s next door neighbor, Togo, using a plan developed with the support of Ghana’s Dr. John Gyapong during a visit by Dr. Gyapong and HDI’s Executive Director. Dr. Gyapong is recognized as one of the world’s leading filariasis epidemiologists and regularly consulted by WHO and others.

Togo’s survey was completed during the final months of 1998 and found lymphatic filariasis to be present in all but one of the regions searched.

Planning is under way for beginning mass-treatment of populations in the affected areas of Togo, and for doing a more detailed search of the area where no cases were found, to be sure pockets of filariasis are not overlooked.

GUINEA WORM DISEASE ERADICATION

- AT A GLOBAL LEVEL

The Reward System

HDI continues to support rewards for finding and containing cases of guinea worm in countries with few enough cases. Our activities to date are summarized in the table on the next two pages.

Fundraising

Our Executive Director intervened with the government of Norway in ways which seem to have facilitated the government’s decision in April 1999, to provide 7.5 million Norwegian kroner (approximately 1 million USD) for guinea worm eradication through the World Bank Trust Fund, for which The Carter Center is the implementing agency.

HDI’S GUINEA WORM REWARDS  -  AN OVERVIEW AS OF JUNE 1999

Country Rewards Since: Amount Comment
Cameroon 1995 23,000 CFA for Cameroonians
03,000 CFA for foreigners
04,000 CFA to reporter
10,000 CFA to villages containing all cases
A complex system was chosen by the program to minimize importation from
Nigeria.
CAR Offered in 1994 Not yet implemented
Ethiopia 1995 20 Birr; Approx. $3.30 each, to patient & case reporter Has neither given the intended enhancement of the surveillance system,
nor proven deleterious.
Gambia Offered in 1994 Not yet implemented
Ghana 1997 1,000 Cedis; Approx. $1.00 each, to patient & case reporter
2,500 Cedis to worm extractor/worm, not HDI funding
Amounts Doubled in November 1998
Uncovered large numbers of previously unidentified cases during 1997 peak
transmission season and thereafter.
Kenya 1996 No cases reported since implementation;
Quality of surveillance and rewards publicity is doubtful.
Mauritania Offered in 1998 Not yet implemented
Nigeria 1999 Rewards offered only in Bama Local Government Area, Borno State, and in South West Zone
Pakistan 1996 30,000 Rupees; Approx. $800 US each to patient & case reporter Rewards supported by UNICEF & others at much lower amounts in preceding years;
Announced by Prime Minister as part of the final precertification process;
Never claimed, but known to >90% of pop., and was thus instrumental to Pakistan’s certification as being gw-free.
Senegal Offered in 1997 Not yet implemented Senegal is planning to only offer rewards to whole villages, not to individuals, to which HDI has agreed.
Uganda 1997 5,000 Ushs; Approx. 3.70 each to patient & case reporter Markedly increased sensitivity for cases and endemic villages in Kitgum.
Yemen September 1994 $100 for the first case in every village;
Now Approx. $50/case
Was instrumental to proving that Yemen had cases, and thus to mustering program financing.
Country Rewards Since: Amount Comment

GUINEA WORM DISEASE ERADICATION

- AT A GLOBAL LEVEL continued

Interagency Meeting at The World Bank in Washington D.C.

HDI was represented by our Executive Director at this meeting, which was hosted by the World Bank on January 13, 1999. Other organizations represented included UNICEF, WHO-Geneva (both in person and through a satellite video-link), the US Peace Corps, The Carter Center, CDC, the UN-Foundation, and the Pan-American Health Organization (PAHO), as well as the World Bank.

Program Review for Francophone Countries in Dakar, Senegal

As an important supporter of interventions in several endemic Francophone countries, HDI was represented by our Executive Director during this April 6-9 meeting.

- COUNTRY SUPPORT

CHAD

In addition to supporting Chad’s guinea worm reward system, HDI stepped in during 1998 to cover the cost of maintaining Chad’s guinea worm secretariat when other major partners failed to provide necessary assistance. This made it possible to continue surveillance and intervention activities there, in a situation where cases had still been reported in two different parts of the country.

With HDI’s support, surveillance was maintained in both of the endemic areas, and a single case was reported in a highly remote part of Chad during September of 1998.

We have recently received a special donation of 5,000 Pounds Sterling from the Flagstaff Trust, which we will use to support Chad’s continuing surveillance and interventions through 1999, in the hope that no more cases are there to be found and that the country thus will enter the 3-year zero-case precertification period.

BENIN, IVORY COAST, and TOGO

We were able to provide technical expertise by funding external consultants with guinea worm field-experience, to spend extended periods of time in each of these three countries during their peak transmission season in 1998, and in Ivory Coast also for the entire three-month 1999 season which recently drew to a close.

The preliminary results look impressive. Guinea worm programs in each of these countries were considered to be in trouble, and the reduction in cases had stagnated in each of them when we decided to offer them external experts.

With HDI’s support, these countries managed to change their situation dramatically.

The three together have reduced their guinea worm cases by over 60% for the first four months of 1999, compared with 1998. Togo’s reduction was 53% for January-April. While Benin reduced cases by 20%, Ivory Coast managed a reduction of fully 80% for the first four months of this year, compared with the same period in 1998.

Francophone Africa in General

Subsequent to the April 6-9, 1999 Guinea Worm Program Review Meeting in Dakar, Senegal, mentioned above, HDI has managed to solicit support of $500,000 to cover a variety of specific unmet guinea worm eradication needs of endemic countries, and to provide continuing external support for Benin, Ivory Coast and Togo, as this intervention was so successful in 1998.

The aim is now to stop guinea worm transmission in all of countries outside of Sudan, at latest by the end of the year 2000.

FINANCIAL REPORT

The separate financial statement and auditor’s report show HDI’s financial situation through June 30, 1998.

We continue to receive extraordinarily generous support for our efforts to eradicate guinea worm disease, and now also for our new effort towards eliminating lymphatic filariasis.