In 2001, the Fund approved a $400,000 technical assistance grant to APOC to help fight onchocerciasis in 19 African countries where millions are still at risk.

The Onchocerciasis Control Program (OCP) which, for 27 years, has worked to contain and possibly eliminate the scourge of river blindness in 11 countries of West Africa¹ is to close down at the end of the Year 2002 in accordance with its set mandate and objectives. The program is considered to have been an important example of effective development cooperation, linking participating countries with donor governments, institutions and private enterprise. The program used aerial spraying (to get rid of the vector), and medication (ivermectin or Mectizan®) to treat the infected, freeing large areas from the disease.

This was the principal message delivered at this year's annual meetings of the governing bodies of OCP and APOC, the African Program for Onchocerciasis Control, held December 10-14, 2001 in Washington, DC. The meetings were JPC-22 and JAF-7², at the joint invitation of the Government of the United States (represented by the US Agency for International Development) and the World Bank. They brought together participating countries, contributing parties and donor agencies and countries, including Kuwait, Saudi Arabia and the OPEC Fund.

Also involved were representatives of non-governmental development organizations (NGDOs) and officials of private industry, including the pharmaceutical firm, Merck, Sharpe and Dohme Incorporated.³

For APOC, the meetings marked the launching of a second and final phase (2002-2007) after which the program is to be concluded in 2010. Thus, the meetings were substantively and symbolically important, as they represented the beginning of the end of onchocerciasis as a major affliction in Africa.

Commonly known as river blindness, onchocerciasis is caused by a parasite, Onchocerca volvulus, transmitted to humans through the bite of the vector blackfly (Simulium damnosum species complex). The flies breed in fast-flowing streams and rivers, hence the association, "river and blindness." Within the human body, the adult female parasite produces thousands of microfilariae (larval worms) which migrate throughout the body, in particular under skin tissue, causing severe itching and skin lesions. Larval worms can also move to the eye, causing irreversible ocular lesions which, after years of exposure, can lead to total blindness. In many endemic areas, the infection is often associated with a high prevalence of epilepsy.

Even today, some 125 million people, worldwide, are still at risk of contracting the disease; 17.7 million are infected (99% in Africa); 300,000 people are "river-blind" and at least 500,000 severely "visually impaired." At the height of the OCP campaign, some 40,000 new cases of blindness were reported per year. Indeed, although the disease has largely been eliminated in the West African OCP area, it is still a public health hazard for more than 15 million people in East and Central Africa.

No drugs exist to kill the adult worm, but a single, annual dose of ivermectin kills the larval worms, which cause the manifestation of the disease. To sustain the beneficial effects of ivermectin (i.e., alleviation of suffering, prevention of blindness and reduced transmission of the parasite), it must be taken annually over an extended period. In 1987, the manufacturers, Merck and Co. decided to provide the drug free of charge to any government making the request and for as long as necessary. The donation, coupled with international financial support, kept the battle against onchocerciasis going, allowing for treatment at minimal cost of millions of people living in severe poverty in the most remote places. The principal delivery method has been CDTI (Community-Directed Treatment with Ivermectin), which empowered local people to assume responsibility over the treatment of their own members, thus facilitating distribution on a sustainable basis.

At the Washington meetings, delegates were informed:

• that both OCP and APOC have been models of international partnerships which have achieved substantial results;
• that river blindness was no longer a public health menace or an impediment to socio-economic development in 10 West African countries which, only a decade ago, were heavily infected; and
• that in the rest of the continent, great strides are being made toward a complete elimination of the disease.

Furthermore, large swathes of land have been freed of the blackfly vector (in the OCP countries) and thousands of young people protected from almost certain infection.

OCP, with headquarters in Ouagadougou, Burkina Faso, has been funded by donor contributions of close to $560 million over its 27-year lifespan. According to its records, it protected 18 million children from ever contracting the disease, and salvaged 25 million ha of arable land for resettlement and re-cultivation. The reclamation is seen as a force against uncontrolled rural exodus. Burkina Faso, for instance, reports that 15% of its land area, previously deserted, is now almost entirely resettled, with agricultural activity thriving.⁴

The Washington meetings were a major step toward bringing OCP to a conclusion. The Ouagadougou headquarters is to be transformed into a Center of Excellence in the Surveillance of Communicable Diseases and handed over to WHO, while some of the Program equipment is to be inherited by APOC.

Among those who reported to the meetings was Dr. Ebrahim Samba, long-term director of OCP from 1980 to 1994 and currently WHO Africa regional Office Director. Dr. Samba told the assembly that OCP success "proved it could be done;" that effective aid programs could deliver lasting results; that African member states contributed in cash and kind, while external donor countries and agencies remained steadfast in their own support. Dr. Samba said all of this had been made possible through hard work, transparency and accountability; and that it had strengthened faith in the efficacy of targeted international development assistance.

The Washington meetings ended with pledges of funding amounting to $39 million to go primarily to the successor APOC to enable it pursue its work in central, eastern and southern Africa. The pledges are also to ensure that the achievements of OCP are safeguarded; that they will be extended to all African communities suffering from the disease and used to monitor and fight other communicable diseases.

Partners endorsed the transformation of the OCP headquarters in Ouagadougou into a center for the surveillance of communicable diseases throughout the region; and the community-directed treatment network will be re-tooled to combat other common, widespread diseases using the same drug-distribution principle. The conditions include lymphatic filariasis (elephantiasis), schistosomiasis (bilharziosis) and Vitamin A deficiency. Most of the drugs needed to treat these afflictions are readily available, and require the same treatment regimen and infrastructure that were developed for onchocerciasis.

The ultimate aim of APOC is to successfully wipe out river blindness as a public health problem throughout the African continent. APOC will continue to distribute the antidote Mectizan®, which the manufacturers have pledged to continue to supply for as long as is needed. APOC hopes to be in a position to distribute the medication to a further 25 million people via 69 projects in 67,000 identified communities in 14 countries. The Program hopes the new funds will be "complemented" over the coming years to reach a total of $80 million to bring the number of people treated to 60 million per year by the APOC closure date of 2010.

Indeed, APOC (also with headquarters in Ouagadougou) was founded to build upon the success of OCP. Thus, the program, in large measure, will continue where OCP left off. APOC was established in December 1995 "to implement self-sustainable CDTI programs in 19 countries outside previously-established OCP areas," where the disease was later found to be equally endemic. APOC covers 19 countries⁵. Its strategy is based on community-distribution of Mectizan®, self-managed by the populations and assisted by national health services and NGDOs.

APOC expects to establish, by 2010, sustainable CDTI delivery systems, treating widespread communities; it hopes to be able to prevent one million cases of blindness; make an estimated 7.5 million additional years of productive adult labor available to the economies of participating countries; protect the $560 million already invested in the West African OCP; and prevent re-invasion of the areas already cleared.

It is expected that the experience of OCP could be replicated to deal with other diseases and problems across the developing world. The OCP/APOC partnership itself could be recreated as a model for international cooperation and methodology for ownership of development projects by local communities. The same approach could, for instance, benefit new programs being scaled up, such as the Lymphatic Filariasis Elimination and the Guinea Worm Eradication programs. The OCP-developed mechanism, ComDT (or Community-Directed Treatment), which played no small part in the success of the distribution of ivermectin could be emulated in the future to reach out and empower those in the poorest, most remote rural areas of the world facing health concerns.⁶

The OPEC Fund has, since 1979, supported the efforts to halt and eradicate onchocerciasis. The Fund holds membership of the governing JPC and JAF and has, over the past 22 years, extended grants worth $2.7 million (to OCP) and $700,000 (to APOC) to assist in their work. The latest grant to APOC is to help with its second and final phases. The agreement ad hoc was signed during the Washington meetings.

At the meetings, the Director-General of the Fund, H.E. Dr. Y. Seyyid Abdulai, applauded the cooperative partnership which accomplished the success the meetings celebrated, and described the involvement of the Fund as being in line with the mandate of the institution, which seeks to do all it can to ease social and economic advancement in the poorer countries of the world. Dr. Abdulai said the Fund was honored to be counted among this partnership against onchocerciasis.

The Washington meetings also honored former World Bank President [1968-1981] Dr. Robert S. McNamara who, in 1974, was largely responsible for the recognition of onchocerciasis as a development threat and the subsequent establishment of the OCP. It was the Bank's first venture into non-traditional, non-finance development cooperation. Dr. McNamara said OCP "has been an enormously effective program; a health program with a development outcome; it has empowered rural communities to banish this burden and thrive." He said he shared the tribute with the many partners and donors and Bank staff "who worked tirelessly to achieve the outcome we celebrate today."

A single dose of Mectizan provides effective protection from onchocerciasis for up to one year.
Distribution of the drug in affected communities is supplemented by medical treatment and research.

¹ Benin, Burkina Faso, Cote d'Ivoire, Ghana, Guinea, Guinea-Bissau, Mali, Niger, Senegal, Sierra Leone and Togo. Originally, OCP was confined to seven participating countries, but it was expanded in 1988 to include others.

² JPC is the Joint Program Committee, the governing body of OCP; and JAF, the Joint Action Forum and governing council of APOC.

³APOC and OCP partners include 30 African countries, the pharmaceutical company Merk and Co., other private firms, 12 non-governmental development organizations (NGDOs), 27 donor countries and agencies and the sponsoring institutions - the World Bank, WHO, UNDP and FAO.

⁴ The image of blindness in Africa is of an elderly man being led by a child, both of them holding opposite ends of the stick. This used to be a common sight in much of the riverine Africa and elsewhere. The "picture" became the "logo" of the onchocerciasis battle in Africa. The current hope is that this image will recede in time, and that such sights will gradually become rare. Statues showing an old man, a boy and a stick now adorn the premises of the World Bank in Washington and the forecourt of the WHO in Geneva, following the success of the OCP.

⁵ Angola, Burundi, Cameroon, the Central African Republic, Chad, the Democratic Republic of Congo, the Republic of Congo, Equatorial Guinea, Ethiopia, Gabon, Kenya, Liberia, Malawi, Mozambique, Nigeria, Rwanda, the Sudan, Tanzania and Uganda. 

⁶ An Onchocerciasis Elimination Program for the Americas (OEPA) exists, coordinating control efforts in six endemic countries of the Americas: Brazil, Colombia, Ecuador, Guatemala. Mexico and Venezuela. It was created in 1992 with the support of PAHO, the Inter-American Development Bank, a consortium of NGDOs and all the affected countries. 

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