Insightinsight

COMMUNITY DIRECTED INITIATIVES IN DISEASE PREVENTION AND CONTROL

The True Spirit of Alma Ata Declaration on Primary Health Care InsightInsight

12345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678901234567890123456789012123456

1234567890123456789012345678901212345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901Oct-Dec042123456 Kanungu “Chief” Speaks about Onchocerciasis

Peace Habomugisha∗ From a variegated background (social, political, geographical, temporal and much more), the reader is led to some keywords, the interview itself and, lastly, to the core of the main speaker’s remarks.

Setting and Time gram goals to his subjects. When he is in Kampala, to cite one Elias Byamungu is the Chief Ad- more, he makes it a point, again ministrative Officer (CAO) of and again, to call at the national Kanungu District in the southwest offices of The Carter Center of Uganda. The writer was sched- Global 2000 to know the latest uled to interview him on April 29, developments, in our plans and 2004 – the occasion of a regional work, that may interest and benefit the people of Kanungu. The idea of limelighting him, did, indeed, arise when we realized In this Issue: that he was a great driving force Kanungu Chief Speaks Kanungu “Chief” Mr. Elias Byamungu, speaks out in CDTI implementation in his about Onchocerciasis area. The fact that he is the ulti- ...... Pgs. 1 - 5 mate controller of his district’s finances, did, also, make him a review, in Kanungu town, of the topic of much attraction and at- A Decade and more of treatment and control of onchocer- tention for our data collection Onchocerciasis Control ciasis. The interview never took and dissemination. with Mectizan place as he had other more pressing ...... Pgs. 6 -10 commitments that day. Weeks later, on 19 May 2004, this reporter did, Key Terms Treatment Updates however, succeed in arranging an- ...... Pgs. 11 Qn. is an abbreviation of ques- other audience with him. Kampala, tion while the acronym ans. this time, was the venue of the ques- means answer. As a matter of News Flash tion-and-answer session between ...... Pgs. 11 course, the reporter asks the the “chief” and the interviewer. Be- questions to which the inter- low, a shortened edition, of record- viewee responds. Clar stands for ings of the meeting, comes to the clarifications made by reader. Why, you will likely ask, was Habomugisha – each of which Publishedby:Global2000 he made the focus of this important RiverBlindnessProgram provoked from Byamungu a re- RiverBlindnessProgram interview? Everywhere in his con- andVectorControlDivision, sponse identified as bym for MinistryofHealth, stituency, Byamungu has been a convenience sake. The former’s Plot15BomboRoad powerful backer of policies and pro- clarifications, on the whole, Typesetby:Global2000, grams of community-directed treat- have to do with issues of sup- RiverBlindnessProgram; ment with ivermectin (CDTI). Thus, port from APOC. Clarifications P.O.Box12027,Kampala for one example, he has crisscrossed aimed to bring Byamungu face Tel:256-41-251025 his district, in the company of our Fax:256-41-349139 Fax:256-41-349139 DOC for the domain, to sell our pro-

This newsletter is supported by The Carter Center, and Ministry of Health - Uganda to face with certain issues, to able but boil it. I also mobilized or more. A tablet of the drug costs which there was no direct atten- people to pressurize government to about $3 at factory price. This is tion from him, in questions asked provide certain amenities through not sustainable for our econo- him minutes earlier. development projects, etc. mies, especially among poverty- stricken communities. In effect, Qn.: How did you know about on- preventive measures, like those The Interview chocerciasis? of Primary Health Care (PHC), Qn.: Can you, please, give us a are the best way to contain the brief history of your work experi- Ans.: When I worked in Fort Portal disease. I understand the drug is ence? there was a Basic Health Services also a good de-wormer and that Project run by the German Techni- is why we need to keep an eye Ans.: I have been in Uganda’s cal Cooperation agency (GTZ); and on it in the stores. If no such se- civil service for 18 years so far, this was in 1988. It had a compo- curity was provided and if the working in various capacities and nent of onchocerciasis control. That proper instructions of using it in districts like Bundibugyo, Fort is where I learnt about river blind- were not adhered to, children and Portal and Ntungamo. I worked in ness, ivermectin, the effectiveness others not supposed to take the the Ministry of Local Govern- of the drug, etc. We were able to drug would access it. ment: There I gained experience eradicate onchocerciasis in the for- as a national trainer for decentrali- ests of Mwenge and the valleys of Qn.: After knowing that much zation and this took me to all parts Bundibugyo. about onchocerciasis how did it of the country. I became a deputy impact on you? CAO in 2000 when I was posted Qn.: What do you know about on- to Ntungamo. I became a CAO in chocerciasis? Ans.: There was an old man in June of 2002 and started working my village, when I was growing in Kanungu in July of the same Ans.: It occurs in places that have up, who had an ailment resem- year. specific physical features such as bling elephantiasis. Once I learnt deep valleys, which are long and about onchocerciasis, I decided Qn.: What have been your major with fast flowing waters and bushes to send him ivermectin. He was challenges and strengths during with canopies. In there is the home very excited and I was happy that the course of your work? of the blackfly, which is responsible I could create such change in for causing river blindness. If it were him. Anything to do with blind- Ans.: My greatest challenge has possible each district should have a ness, talking generally, makes me been to open up closed places, functional vector control unit, part scared stiff. After knowing about which have not had a serious dos- of whose work would be to gather onchocerciasis and the problems age of public investment, e.g. in these flies and determine how and it can cause people, I have had to Bundibugyo. There, there were no when the health ministry and local be personally involved in activi- proper roads and no good houses. government can and should inter- ties for curbing the disease. Al- By the time I left, however, many vene. I was taught that when the fly most always, indeed, I push good houses had been built; a bites people, it takes some time be- Kanungu’s District Onchocercia- good road had been constructed; fore symptoms of the infliction, sis Coordinator to carry out well and one can now take only 6 hrs such as hardening of skin and its his duties. from Fort Portal to Bundibugyo as peeling off as if it has been burnt, opposed to the original 12-hour appear. Some cases of it are similar Qn.: What, however, are some of journey. to elephantiasis – the feet become the specific roles that are played so huge. Taking the ivermectin drug, by you and your district in the My strength is to simplify myself. early, can reduce these problems. It combat of onchocerciasis? If there is no electricity, I work takes a long time to treat this without it; no flowing water, I malady: one needs to swallow the Ans.: Social mobilization is one. manage with the little that is avail- drug once a year for about 10 years I call all LC1s twice a year to

2 brief them about our achieve- ments and challenges in the struggle. As a matter of accountability, I give them figures of how much was disbursed to their villages. This also influences them to demand accountability from their sub-county authorities.

Without fail, I ask people, in Kanungu’s affected areas, to con- firm that they receive ivermectin, to discourage users of the drug from opting out of the treatment and control scheme, and to always let me know if they are benefiting from the medical service. Looking on is the CAO at a workshop

The district’s responsibility is to ensure that financial and other re- Qn.: What have been the benefits and other people to talk about sources are mobilized in order to of the onchocerciasis program in problems of onchocerciasis. contribute to the onchocerciasis Kanungu? More attention would surely be program: Each sub-county makes paid by the public because such a token contribution. We still have Ans.: They are immense! I cannot voices as mine are familiar to a problem with the LC3s, though, compute them in monetary figures. them. Different people, with because they do not prioritize on- The disease has declined tremen- great authority, would indeed chocerciasis in their plan. dously. No new cases are coming make a difference through such up. Although we cannot measure air programs. Qn.: What have you found fasci- them accurately, we can say, “We nating about your involvement in have almost eliminated this prob- Another weakness is that on- those activities? lem.” chocerciasis control is not yet fully integrated in the overall dis- Ans.: Every time I call at a sub- Qn.: What holes exist in the pro- trict development plan. It needs county’s head offices, I learn gram? to be regarded and treated as a something new. For instance I re- district activity and not a Global cently discovered that some sub- Ans.: Our communication strategy 2000 activity. Purchases of drugs county officials are extracting tax is not without flaws. We produce by the District Medical Officer from sick individuals, including bulletins but as you know some (DMO), for instance, should in- casualties of onchocerciasis. I in- people have not cultivated a read- clude ivermectin so that it be- structed them to exempt these ing culture; so when they receive a comes readily available from people. Rural peasants are open to bulletin, they just sit on it. Use of sub-health centers or from a large extent; they do not hide radio to communicate messages di- among designated distributors in many things. For example, if a rectly to the communities, as many the affected communities. man is impotent, he would say, “A people have personal wireless sets, sheep has stepped on me,” entama which they only have to turn on to Facilities for trapping the black- ekandibata. The openness enables listen in to programs on the air, is fly is a need that is still largely us to work out how best we can one way of combating this. We unmet in Kanungu. This con- help them. could use the local FM radio station trasts sharply with the experience and have a health educator, or me, I had in Fort Portal where we had

3 traps, which were used to collect taxation, otherwise without a tax is what we would like to know insects and put them on charts. base where will money come from? now. We were consequently able to We request APOC to avoid with- monitor their behavior, their num- drawing abruptly from Kanungu. Bym: When one signs an agree- bers, how they were multiplying Their disengagement, ideally, ment, you know, s(he) should themselves, and so on. The Min- should be gradual and systematic, obey its obligations; but a treaty istry of Health apparently needs thus allowing for reductions in their can be reviewed. So we request to see how to get traps for the activities over a stretch of time. In the funders (APOC) to reconsider onchocerciasis program, place the meanwhile we shall arouse dis- the agreement, bearing in mind them in the different areas where trict authorities to step up local con- what we have been discussing, they are needed, and assign to cer- tributions in funds and other things. especially because the cost of the tain individuals the business of When it has been started, an on- drug is so high for the majority tracking down the flies. The catch chocerciasis program should not of the unwell. We are thus still would then be taken for exami- take just 3 years; it needs extending hoping that APOC can reverse its nation and analysis in various to 5 years or more to give us enough departure because we do not yet laboratories. time to adjust.

Qn.: Now that APOC has pulled out, what are you planning to do as a district to ensure that the program continues?1

Ans.: This is a challenge. Politi- cal leaders, who are pushing to remove graduated tax, are my major problem, however. I just request them to put very little pressure on the central government until there are alternatives. The problem with the tax is the significantly inhumane method of its collection. So many bad things happen when it is due. One time in Fort Portal, for example, an old woman was killed during an op- Community members in Kanungu district identifying oncho symptoms eration to enforce payment of graduated tax. In such other places as Ibanda and Kitagwenda, Clar: APOC’s agreement, however, have much, on the ground, in con- respectively in Mbarara and was very clear: that after 5 years it crete preparedness for the change. Kamwenge districts, when you will pull out and the district will take hear people say, “It will rain to- over the ownership, administration Clar: Be assured, Mr CAO, that night,” it means there will be a and financing of the program. This the American Merck Co. Inc., the crackdown on evaders of the tax. is well known to the district and its maker and donor of ivermectin, Defaulters, who are nearly always people, and their engagement was did agree to continue supplying men, usually run away at this brought to a close on April 30, 2004. the drug. Uganda offices of The time. There ought to be other pro- The organization’s retreat was there- Carter Center Global 2000, gressive methods of teaching and fore something not abrupt. What though, have one concern: Would requiring people to contribute to- measures you have put in place, it be easy for Kanungu people to wards their development through knowing that APOC would pull out, get the drug in the absence of

4 APOC? Would your district be in tried the concept in a certain committed, is a persistent problem in position to be accountable to the munity. We asked them to dig Kanungu and some other districts drug company? trenches to stop wild game from of Uganda. Attempts to restrain eating people’s crops. After that, we or eliminate it, such as in Bym: Purchases of the drug was gave them 2 kilograms of sugar each Kanungu and the three districts my main worry; but if the com- as a token of appreciation. of Kabarole, Kamwenge and pany will continue taking care of Kyenjojo (which formerly consti- that, then the rest will be man- In this concept you will see the ful- tuted Fort Portal) and mostly with aged by us. Manpower and other fillment of the 3Rs of motivation: considerable foreign financial, necessary resources can be pro- recognition, responsibility, and re- material and other assistance, are vided without great difficulty: ward. Implementation of the con- acknowledged, appreciated and We have in place a whole essen- cept, to materially maintain the su- applauded by him. Another, and tial support system, including pervisors, is not a challenge in and no less weighty characteristic is community distributors. Sub- of itself because some of our people that he is a great believer that the counties will contribute sums of have tried it before and they will self-help aspect of CDTI can be money they can afford. continue to fall back on this strat- immensely increased, up from its egy. current low levels. More specifi- Clar: The Carter Center Global cally, he has huge faith that 2000 is concerned about commu- Fundraising, for the cause of check- Kanungu folk will sustain CDTI nity supervisors. These are not ing onchocerciasis, is the second as it will no longer be possible government employees. They do plan on our table in the post-APOC for them to source significant not earn a salary, yet they do a regime. We also need to discover material support from APOC. lot. They do health education as and put to maximum use all other The interviewer helped him to they supervise distribution of potentials, at district and sub-county come to terms with the fact that ivermectin, they train drug dis- levels, for money generation. Eco- APOC was gone, and that the tributors, and they make sure that nomic, social and other transforma- clock could not be rewound. If we accountability is forthcoming. If tion, which we often hear of from go by what he has already done the district could support these Ugandan President Yoweri in CDTI’s interest as well as by people, then it would probably Museveni and others, does actually his still unimplemented plans for maintain the assault against on- result from all such resourcefulness. the program, Byamungu cuts the chocerciasis. You people could, If drugs are free but we fail to mo- figure of a practical man, a vi- furthermore, make simultaneous bilize a community to benefit from sionary. How Kanungu will run use of the supervisors in other them, do you not think that is a scan- CDTI in big style, without the district programs. So, how are dal? The failure would mean that substantial help of good-doer you going to sustain them? district administrators would cease APOC, does, however, remain to to qualify to be leaders in the strict be seen. Bym: From Norway we recently sense. Approaches such as those we got a visitor who introduced me have discussed will enable us to * Information expert Julie Gipwola to the concept of “food for work”. have funds to spend, and even more played no small part in my resolve to This is how it is utilized: People to stash away in reserves for the fu- meet, and extract from, Byamungu ma- set aside their own duties, for a ture. terial for this text. Deserved recognition goes to her. period of time, and do community work. My task now is to in- 1 It was on 30 April 2004 that APOC terest my councilors in this con- finally wound up its formal involvement, cept, and show them that this is of many years, in Kanungu. This was a priority area. “Food-for-work” one day after the date, 29 April 2004, Byamungu’s utterances have many of our original appointment to interview laborers need little food for work qualities, two of which shall now be Byamungu in Kanungu’s capital center done by them. Sometime ago I our focus. Onchocerciasis, it is ad- – an appointment that did flop. End 5 A Decade and More of Onchocerciasis Control with Mectizan

Christopher Ruzaza1

Introduction A description of the process, the successes as well as the needs and difficulties of mass treatment programs with Mectizan, this contribution significantly repre- sents the story of the author’s personal fieldwork experience of some thirteen years, 1992-2004. For people, to whom this area is of some concern, it is an account that they may wish to hear. The many parts – brief information about the presenter, the era of preliminary surveys and rapid epidemiological mapping of onchocerciasis (REMO), that of the community-based Mectizan distribution program, the introduc- Mr. Ruzaza Christopher at the Carter Center offices tion of CDTI strategy and its challenges,2 a discussion and possible way forward as well as ordinator (D.O.C.) – with the two control mechanism; the most cen- some closing remarks – into districts of Kabale and Kisoro, in tral promoter of its child de- which the story is broken up, south-west Uganda, as the sphere of worming and vitamin-A supple- make it readable. his work. The region lies about 450 mentation program; a member of kilometers from Kampala, Uganda’s the District Health Management capital city. Team (DHMT), a body charged Some Biodata with planning and implementa- The author is a holder of a di- As the Ministry of Health wished tion of the district’s health ser- ploma in Medical Entomology to strengthen the control of vector- vices; and a district trainer in such and Parasitology. His career in borne diseases, in the newly created things as CDTI and the control health started in 1989 when he district of Kisoro, the author was of vector-borne diseases. was appointed an Assistant En- later transferred from Kabale to tomological Technician at the Kisoro where, to this day, he re- In the area of onchocerciasis con- headquarters of Uganda’s Vector mains D.O.C. and Vector Control trol, the author has a certificate Control Division, a department Officer. Kisoro District, after recog- of merit from Global 2000 River under the country’s Ministry of nizing the author’s potential in Pri- Blindness Control Program Health. He was to fill this posi- mary Health Care (PHC) implemen- (GRBP, Uganda). Ruzaza has tion until 1991 when he was el- tation as well as in the control of participated in an international evated and posted to Kabale as a vectors, did allot the officer addi- workshop in Nigeria’s Enugu District Vector Control Officer. tional duties: He was made District State. This was in 1997, and the More promotion was only Field Coordinator for the malaria assembly was about the impor- months away. In 1992 he was control programme; the focal execu- tance of streamlining CDTI field assigned the office of District tive of the district’s integrated dis- operations. Onchocerciasis Control Co- ease surveillance and epidemics

6 After recognizing this author’s re- them for identification. The next mapping and the REMO on foot search potential, the African agenda was usually community mo- – walking, sometimes, for 3 to 5 Programme for Onchocerciasis bilization, with the communities hours in the hilly slippery paths. Control (APOC) sponsored him being invited for meetings, which Those days we did not have mo- to undertake, under Uganda’s would be used to educate and sen- torcycles for field trips. Nobody, Ministry of Health, a 6-month sitize these communities on on- moreover, at that time, would talk course in research methodology chocerciasis. For each village, we of a vehicle, for this activity, be- and computer methods in 2002. finally used to ask for volunteers for cause there was only one rough On this he did very well. As a re- rapid determination and assessment road, through the forest, which, sult of this training, he later served of onchocercal prevalency in that most times, was not fit for motor as a member of a 3-person team particular area. traffic. Accommodation itself that carried out, on behalf of was not easy to find: So we used WHO and APOC, an external Community members quite often to stay with the village leaders in evaluation of the Kabale District volunteered when the method used their small houses, which, in most CDTI program. was “rapid nodule palpation” or cases, were thatched with grass. simply searching of the body for We used to carry with us food, presence of onchocerciasis nodules. clothing, beddings and health Era of Preliminary Surveys However, it was very difficult to equipment from village to village. and REMO convince them to volunteer for skin “Wanderers” of the villages we There was no clear picture in 1991 snipping: this action, for them, was were. We would spend 2-4 weeks of the endemicity in Uganda of like cutting a big portion of their in villages without visiting our 6 onchocerciasis. The last compre- buttocks and then taking the flesh families in Kabale town or else- hensive surveys had been done in to the bazungu5 to create some where. Life was challenging, but 1975. No clearheaded scientist, magic for stopping procreation we were committed to make the however, in the 1990s, would rely among the communities. Once these Mectizan donation program a re- on the 1975 data for control of the communities stopped giving birth, ality among the communities. condition. When I was at college it was believed, all the villages (1996-1998), all that was known, would be annexed to Bwindi Forest of the existence here of onchocer- Reserve, a big sanctuary for moun- Days of Community-based ciasis, was still a rough sketch, By tain gorillas that the Bazungu like Drug Distribution then, though, as illustration from seeing so much. We would tell them Our new task, after mapping on- my own work background shows, the usefulness of skin snipping, ob- chocerciasis endemic villages, in some vital fieldwork had been serving that if onchocerciasis were Kabale and Kisoro, was to give done in some of the country’s dis- proved to have high incidence in the Mectizan drug to entire com- tricts where the disease was com- their villages, they would receive munities, particularly to eligible mon. Mectizan virtually free of charge. individuals and families. Health Community members, at times, workers were too few for the task; During 1992, with support from would refuse volunteering on the and clinical work, at the few ex- the River Blindness Foundation,3 first day. In such circumstances we isting facilities, was too much. we set off to establish and map would extend our negotiations for a We hatched the idea of identify- onchocerciasis endemic villages 2nd day, and even for three days run- ing and training community in Kisoro and Kabale districts. We ning. On the whole it was indeed members to assist the health visited villages in and around tough to convince them to accept to workers specifically chosen to de- Bwindi Impenetrable Forest: all be skin-snipped, but somehow we liver treatment to the communi- this while we tried to establish the succeeded and we were able to map ties. For effectiveness and com- existence of the black flies4 all the onchocerciasis endemic vil- munity participation, local lead- through local reports or at times lages and to determine the rate of ers were groomed to assist in mo- by using ourselves as baits for occurrence, in every community, of bilizing community members as black flies to bite so as to catch this condition. We did most of the well as in providing them with

7 health education. directed system in 1996, we were lessly for thirty days including achieving over 80% treatment cov- Sundays. When our Kabale team Various improvisations enabled us erage of the eligible population in finally left Nebbi to return home, to weigh and measure the heights over 70% of our communities. over 50% of its onchocerciasis of the community members, after cases, real or potential, had been which we started mass treatment No less interesting are my experi- treated. These beneficiaries were with the members taking ences in Nebbi District, in Uganda’s spread over 100 villages. Mectizan on the spot. We kept our West Nile region, in the country’s records in exercise books; and at Northwest. About these, though, I Advent of CDTI Strategy the end of each month, we had to shall talk very briefly. By 1994, and Associated Challenges produce a treatment report. There some pioneers, myself among them, We had not anticipated that mass were then no pre-designed report had successfully established the an- treatment of onchocerciasis-en- formats. My subsequent involve- nual Mectizan distribution program demic communities would take ment in designing and developing in the three districts of Kabale, over 10 years. Therefore there such formats, which are in use to- Kisoro and Rukungiri, mostly near arose the issue of the day, was a gratifying experience. the Bwindi Impenetrable Forest. sustainability of long term Indeed we learnt by doing many Kampala’s Country Office of the Mectizan distribution and treat- things. Later we were to discover River Blindness Foundation re- ment program. At a national con- that there are activities and pro- quired our experience to establish ference, some scientists pre- cesses that one had to pass through similar programs in Nebbi. We sented the results of a multi- to achieve good treatment cover- packed our bags. We also dis- country study on the age. As a result, we started plan- mantled some parts of our motor- sustainability of Mectizan treat- ning and implementing such ac- cycles so that these motorbikes ments; and, consequently, we tivities as taking a community could fit in the motor vehicle of the adopted the community-directed census, community sensitization Foundation’s Country Office. Ours strategy. Its initiation did, how- and mobilization, training of drug was a long journey – via Kampala, ever, require reasonable funds. distributors,7 and others. travelling all the way to and through APOC’s management staff, at Karuma falls. Three days, after we one meeting, promised to fund Traveling through the hilly terrain, set off, we arrived in Nebbi. Many the implementation of the new when our transportation im- of the roads, which we took, were strategy for five years, after proved, was still difficult. One rough, with potholes, and we were which the government of Uganda would only reach about 20% of very tired when we reached our des- and the onchocerciasis endemic the communities on a motorcycle, tination. We rested for one day as districts would sustain the mass for example, on any one day. Su- the Nebbi D.O.C. oversaw the re- treatment program. With the pervision of mass treatment and assembling of our motorcycles, change in strategy, many advo- collection of reports from indi- which were soon to be packed in the cacy meetings were held. Gov- vidual CBDs, despite the devel- boot of a larger vehicle. REMO had ernment and district officials, opment, remained hard. Some- been done by a mobile group with whose support was in high de- times one had to find a CBD in a its base in Kampala: Our task was mand, would also be invited to garden some 3 km away from his mainly to establish, in Nebbi com- these gatherings. Series of train- or her home to get a report from munities, a Mectizan distribution ing seminars helped to re-orient him or her. and mass treatment system. Local health workers as well as com- languages in the district were a community resource persons, includ- With much dedication of the key munication barrier for me, and I ing drug distributors and local stakeholders, at various stages, worked through an interpreter. leaders. from national to village level, While such indirect communication treatment was generally success- was a challenge, at the start, I New challenges have risen dur- ful, none the less. By the time we quickly adjusted, and my work went ing the CDTI era – since 1997 to moved from the community- on smoothly. The Nebbi D.O.C., my be more specific. The good news based approach to the community- Kabale colleague and I worked tire- is that, for every new challenge

8 have used 3 brand new motorcycles. Old age, while still they were in use, reduced them to scrap. Over 100 times, I fell off the motorcycles; my Kabale colleague died after a motorcycle accident, and, indeed, many other onchocerciasis officers, else- where in Uganda, have died or have been crippled as a result of riding on bad roads and terrain.

Onchocerciasis control is quite an expensive venture, both in personnel terms and logistics provision. It requires strong com- mitment and a lot of sacrifice Mr. Ruzaza speaks to men in a community from a D.O.C. or other CDTI implementers. The spirit of service above self must prevail if we that crops up, we have either been CDTI program. The findings indi- must run the Mectizan distribu- able to find a solution or we are cated that the program was making tion programs successfully. Com- still on track looking for answers. reasonable progress towards munity awareness, through con- Challenges, over the years, have sustainability. Kisoro District, as we stant health education and infor- included such constraints as write or read this, has committed mation dissemination, should be these: part of its annual budget to CDTI maintained, using appropriate in- • Funding from APOC was implementation, now and later, al- formation education and commu- not always timely. though this is not sufficient. I am nication (I.E.C.) strategies. • Some health workers, optimistic that, as a district, we shall drug distributors8 and continue to adjust to meet the latest other stakeholders re- challenges. As a D.O.C., I feel, in- Conclusion sisted the change to CDTI deed, that it is part of my duty to Onchocerciasis control is a life- because the approach look for solutions to challenges threatening task, but we should does not generously re- ahead of us. endeavor to save our people, who ward them financially. are doomed to poor health and • Implementation of the Discussion and the Future poverty by the disease. new strategy required The Mectizan distribution program consistent contact and is a challenge because onchocercia- America’s Mark & Sharp Com- dialogue with community sis is usually endemic in hard-to- pany has contributed enor- members, which was tire- reach areas. As one has described mously, through its gifts of some and costly. it, it is found “at the end of the road” Mectizan, for the betterment of • The communities se- so to say – a statement borne out by the world’s onchocerciasis en- lected many CDDs and some of my own career experiences, demic communities. Without this supervisors who required some of which I already narrated. drug, these communities would intense training, follow be hopeless, and I personally up and supervision by the Efficient transport systems are a would have not the kind of field few existing health staff. must if high treatment coverage is experiences and stories shared to be maintained. We have this ex- here. In the year 2002, there was an example: Since 1992, as a D.O.C., I ternal evaluation of the Kisoro

9 Complementary Reading 1 The older edition of this transcript was 4 These vectors, also called simulium Ruzaza, Christopher. 12th July written and submitted for the Mectizan flies, are the cause of onchocerciasis. Donation Program Award. It has been ed- 2004. “Problems and Issues to 5 Bazungu, or (a)bajungu, is the generic ited to suit the standards of this newsletter. Address to Ensure Sustainability name for Europeans and others of that 2 CDTI is an abridgement of community- of CDTI in Kisoro District.” Un- kind. directed treatment with ivermectin. published text addressed to the 6 The capital center of Kabale District. 3 The organization ceased, in the 1990s, to The National Onchocerciasis 7 Who, at that time, were called Com- exist in Uganda, but its effort to contain munity-Based Drug Distributors Task Force (NOTF) Secretariat, onchocerciasis there was taken over by the (CBDs). Ministry of Health, Uganda. Ar- Uganda department of The Carter Center 8 chives of The Carter Center Glo- Global 2000; thus the ‘Global 2000 River Usually known as community-directed distributors (CDDs). bal 2000, Bombo Rd., Kampala. Blindness Program (GRBP)’ of The Carter Center.

Season’s Greetings and Prosperous New Year

Health Education Objective 2004

District No. of No. of communities No. of communities % Achieved communities targeted covered Adjumani 218 218 91 41.7 Apac 9 9 9 100 Gulu 187 187 139 74.3 Kabale 48 24 24 100 Kanungu 105 41 25 61 Kasese 131 0 0 0 Kisoro 32 32 25 78.1 Mbale 580 580 306 52.8 Moyo 189 100 98 98 Nebbi 670 670 572 85.4 Sironko 191 191 50 26.2 Total 2360 2052 1339 65.3 Training Objective 2004 CDDs Community Supervisors H/workers from FLHF District Annual Actual % Trained Annual Actual % Trained Annual Actual % Trained Training Trained Training Trained Training Trained Objective Objective Objective Adjumani 2746 2746 100 436 436 100 168 155 92.3 Apac 155 155 100 20 20 100 12 12 100 Gulu 3224 3224 100 179 179 100 70 40 57.1 Kabale 522 522 100 95 95 100 12 11 91.7 Kanungu 1928 1928 100 210 210 100 19 9 47.4 Kasese 779 775 99.5 262 262 100 232 132 56.9 Kisoro 394 394 100 64 64 100 19 9 47.4 Mbale 10043 10043 100 1160 1160 100 132 121 91.6 Moyo 2300 2213 96.2 378 378 100 317 117 36.9 Nebbi 10618 10618 100 1,340 1,340 100 349 112 32.1 Sironko 1522 1522 100 382 217 56.8 35 25 71.4 Total 34231 34140 99.7 4526 4361 96.3 1365 743 54.4

10 Treatment Updates (Oct - Dec 2004)

Name ofTotal Popn Popn Ultimate Total Popn TXNo. of Active Active Active District Popn treated treated Tx Goal Popn TX % of UTG Villages villages villages villages % during cumulative (UTG) for % for 2004 treated cumulative UTG for UTG current for 2004 2004 2004 during the for 2004 for 2004 for 2004 month current month Adjumani 171,128 143,012 146,563 83.6 97.6 218 218 100 Apac 15,672 12,808 12,818 81.7 99.9 9 9 100 Gulu 204,879 140,114 150,660 68.4 93 187 187 100 Kabale 17,475 13,796 15,235 78.9 90.6 48 48 100 Kanungu 46,448 37,635 38,873 81 96.8 105 105 100 Kasese 95,717 79,505 79,637 83.1 99.8 131 131 100 Kisoro 21,315 16,027 17,861 75.2 89.7 32 32 100 Mbale 179,749 139,982 140,091 77.9 99.9 580 580 100 Moyo 177,788 139,019 140,069 78.2 99.3 189 189 100 Nebbi 283,519 231,950 232,546 81.8 99.7 670 670 100 Sironko 59,789 49,089 49,905 82.1 98.4 191 191 100 TOTAL 1,273,479 1,002,937 1,024,258 78.8 97.9 2,360 2,360 100

News Flash

October November From 17th to 23rd October 2004 a 6th /10/2004, The Carter Center Peace Habomugisha met Dr. Don surveillance team traveled to staff held a one day meeting with Hopkins and Mr. Craig at Entebbe Kanungu district to monitor CDTI all the DOCs from the 11 districts Botanical Beach Hotel and dis- activities through face-to-face inter- supported by The Carter Center cussed important issues concern- views with household heads, Global 2000 at their national of- ing onchocerciasis program. In CDHS, CDHW and community fice, Kampala to review the addition, Craig Withers paid a leaders. progress of CDTI activities. They courtesy call to GRBP office in shared field experiences, suc- Kampala. The Carter Center staff were in cesses and challenges of CDTI Kasese district from the 24th to 30th and how to overcome them. From 15th to 20th November 2004 October 2004. They witnessed and Peace Habomugisha, Stella gave advice where necessary, the 12th to 23/10/2004, a group of En- Agunyo and a surveillance team district leaders training health sub- tomologists, vector control offic- traveled to Mbale district to moni- district officials, sub county leaders, ers including some DOCs who are tor CDTI activities through face- health workers and community-di- experts in skin snips together with to-face interviews with household rected health supervisors (CDHS) in medical doctors from Moyo did heads, CDHS, CDHW and com- CDTI work and how they could in- skin snipping and clinical exami- munity leaders. Peace also tracked tegrate CDT into other health and nation of the disease in Moyo dis- ivermectin form the district down developmental programs. This was trict. Data is still being entered to the health units in both Mbale done in a bid to ensure sustainability into the computer for analysis. and Sironko districts. of CDT activities at these levels.

ChiefEditor:PeaceHabomugisha

EditorialBoard:RichardNdyomugyenyi,A.W.Onapa,StellaAgunyo,HarrietSengendo

11 The Carter Center Global 2000 River Blindness Program, Uganda P. O. Box 12027, Kampala. Plot 15 Bombo Road Vector Control Building Ministry of Health Tel: 256-41-251025/345183 Fax: 256-41-349139 Email: [email protected]

TO: