Document 12921228

<window type="generic" extraspaces="use" wordwrap="true" width="320" duration="00:57:23.50" bgcolor="#000000"> <center> <time begin="00:00:00.56"/><clear/>>> I'm Dan Colley, and it's my pleasure to welcome you to the third lecture <time begin="00:00:05.77"/><clear/>in the 2008 series Global Diseases, Voices from the Vanguard. <time begin="00:00:11.97"/><clear/>As most of you know, this is a joint effort between the Center For Tropical <time begin="00:00:15.56"/><clear/>and Emerging Global Diseases, and the Knight Chair in Health and Medical Journalism <time begin="00:00:21.26"/><clear/>in the Grady College of Journalism and Mass Communication. <time begin="00:00:25.70"/><clear/>AKA, Pat Thomas, and a group of others who make this happen. <time begin="00:00:31.22"/><clear/>This series brings together those with wide-spread interests in global health, <time begin="00:00:36.56"/><clear/>from across the breadth of the UGA campus and to some extent people out in town. <time begin="00:00:43.39"/><clear/>And I thank each of you for coming this evening. <time begin="00:00:46.78"/><clear/>Today we have an excellent speaker. <time begin="00:00:48.49"/><clear/>Someone who both mans the front lines and knows the inner workings of global health. <time begin="00:00:55.65"/><clear/>Dr. Frank Richards. <time begin="00:00:57.78"/><clear/>Frank is at the Carter Center, but before I introduce Dr. Richards I'd <time begin="00:01:03.82"/><clear/>like to mention the remaining Voices from the Vanguard lecture for this semester. <time begin="00:01:08.59"/><clear/>On April 15, yeah, tax day, we're pleased to have Dr. Anne De Groot <time begin="00:01:15.24"/><clear/>from Brown University and EpiVax as our speaker. <time begin="00:01:20.37"/><clear/>And after hearing today's lecture I hope you will want <time begin="00:01:22.71"/><clear/>to come back next month and hear Dr. De Groot. <time begin="00:01:26.11"/><clear/>One other announcement. <time begin="00:01:27.78"/><clear/>As usual after these lectures there will be a reception next door in Demosthenian Hall. <time begin="00:01:33.39"/><clear/>So right after the lecture, out and to the left. <time begin="00:01:38.22"/><clear/>So this evening's speaker was born in Bitburg, Germany, but we still think we could run <time begin="00:01:44.80"/><clear/>for president because he was born in the U.S. Air Force base in Bitburg. <time begin="00:01:48.87"/><clear/>So he's still a viable candidate. <time begin="00:01:51.63"/><clear/>He doesn't remember much about Germany, <time begin="00:01:55.38"/><clear/>but that international flavor must have rubbed off somehow, because after being raised <time begin="00:02:01.84"/><clear/>in St. Louis, graduating from Williams College and Cornell University Medical College, <time begin="00:02:08.88"/><clear/>he has since worked in more than 15 countries and lived for 5 years in Guatemala. <time begin="00:02:15.40"/><clear/>Dr. Frank Richards is a board certified pediatrician <time begin="00:02:18.39"/><clear/>who has spent his entire career focused on global health. <time begin="00:02:22.52"/><clear/>After house staff training at Children's Hospital in Los Angeles, <time begin="00:02:26.57"/><clear/>he joined the commission corps of the United States Public Health Service at the CDC <time begin="00:02:31.95"/><clear/>and his calling has been almost entirely centered on tropical disease control, <time begin="00:02:37.28"/><clear/>elimination, and eradication programs in the Americas and in Africa. <time begin="00:02:42.78"/><clear/>As you will hear, both at CDC and more recently at the Carter Center, <time begin="00:02:46.96"/><clear/>Dr. Richards has championed and led control programs against some <time begin="00:02:51.20"/><clear/>of the world's worst scourges in some of the world's most challenging places. <time begin="00:02:57.10"/><clear/>He is a world leader in creating new ways forward in the difficult area <time begin="00:03:00.74"/><clear/>of tackling multiple diseases in a coordinated manner. <time begin="00:03:05.96"/><clear/>Dr. Richards has been honored nationally and internationally for his work. <time begin="00:03:09.92"/><clear/>He exemplifies the breadth and depth of what I think a public health physician, <time begin="00:03:14.75"/><clear/>medical epidemiologist can bring to the global health challenge. <time begin="00:03:19.74"/><clear/>And I'm very pleased to present him to you this evening, <time begin="00:03:22.80"/><clear/>as our March 2008 Voices from the Vanguard lecture. <time begin="00:03:27.08"/><clear/>Frank? <time begin="00:03:28.30"/><clear/> <time begin="00:03:29.51"/><clear/>[ Applause ] <time begin="00:03:36.34"/><clear/>>> Well, good evening. <time begin="00:03:37.28"/><clear/>Thanks, Dan, for that introduction. <time begin="00:03:39.22"/><clear/>I think Dan didn't mention that he was my boss for five, six, <time begin="00:03:43.86"/><clear/>seven years when he was the director of the division of parasitic diseases <time begin="00:03:48.48"/><clear/>at the Centers for Disease Control. <time begin="00:03:50.51"/><clear/>And he was a great boss and very supportive <time begin="00:03:52.55"/><clear/>of what I was trying to do, and I thank you for that. <time begin="00:03:55.49"/><clear/>And I thank you all for coming tonight. <time begin="00:03:58.62"/><clear/>My topic tonight is: Bundling Grass Root Services <time begin="00:04:03.46"/><clear/>to Battle Neglected Diseases in Africa: A Journey to Nigeria. <time begin="00:04:08.95"/><clear/>It's kind of hard to live up to the flyers that <time begin="00:04:15.28"/><clear/>I have seen here on what I'm supposed to be. <time begin="00:04:20.67"/><clear/>I'm supposed to be one of four charismatic scientists who are inviting you <time begin="00:04:26.70"/><clear/>to help me defeat infectious diseases that thrive in poverty <time begin="00:04:30.58"/><clear/>and kill millions of people world wide. <time begin="00:04:33.52"/><clear/>So I'm the third charismatic scientist to be with you. <time begin="00:04:38.82"/><clear/>I hope I can live up to that billing. <time begin="00:04:42.18"/><clear/>I want to review very quickly what Dan just said to let you know sort <time begin="00:04:45.90"/><clear/>of who I am and what my orientation is. <time begin="00:04:49.19"/><clear/>And I usually use the P's to do that, to explain to people what I do and what my interests are. <time begin="00:04:56.50"/><clear/>The first is pediatrics. <time begin="00:04:58.38"/><clear/>I'm trained in pediatrics. <time begin="00:05:00.17"/><clear/>The second is I have a passion for parasites, and in particular, <time begin="00:05:04.23"/><clear/>my passion for parasites relates to worms. <time begin="00:05:07.48"/><clear/>So I'm mainly going to talk to you about worm parasites of human beings. <time begin="00:05:13.20"/><clear/>Then these worm parasites of human beings usually affect people living <time begin="00:05:17.23"/><clear/>in dire, abject poverty. <time begin="00:05:19.18"/><clear/>Really, people living under a dollar per day. <time begin="00:05:23.46"/><clear/>So the poor is an important element in what I do. <time begin="00:05:26.85"/><clear/>And I'm not a clinician. <time begin="00:05:27.87"/><clear/>I'm trained in clinical medicine, <time begin="00:05:29.24"/><clear/>but my interest is preventing disease in public health. <time begin="00:05:33.74"/><clear/>And it's not just in public health, it's in programs. <time begin="00:05:36.54"/><clear/>So I don't really think of myself as a scientist, per se. <time begin="00:05:40.03"/><clear/>I really think of myself more as a program person. <time begin="00:05:45.48"/><clear/>Pills is the next P. I'm involved with tablets, with passing out pills. <time begin="00:05:51.13"/><clear/>I'm sort of a pill roller, if you will, with collaborators around the world. <time begin="00:05:56.36"/><clear/>And these tablets are tablets which have been developed really in the last 30 years, <time begin="00:06:01.96"/><clear/>remarkably safe, that can have really dramatic impact on people's lives. <time begin="00:06:07.78"/><clear/>And I called these the poor man's vaccines. <time begin="00:06:10.71"/><clear/>You don't need needles to distribute these, <time begin="00:06:12.58"/><clear/>you don't need refrigerators or what we call cold chains. <time begin="00:06:16.43"/><clear/>So it's really a great opportunity, a new technology, that is even more germane <time begin="00:06:24.78"/><clear/>to fighting diseases in the poor because we have what we call public private partnerships, <time begin="00:06:31.94"/><clear/>where industry, big pharma, is donating these medicines and asking others to come together <time begin="00:06:40.10"/><clear/>around a donation to help find the resources and the logistics and the mechanisms to treat people <time begin="00:06:46.98"/><clear/>who are in very remote communities. <time begin="00:06:50.74"/><clear/>Any time you talk about public private partnerships or any time you talk <time begin="00:06:54.34"/><clear/>about public health you're really talking about power relationships and politics. <time begin="00:07:00.01"/><clear/>And so I'm very lucky to work with President Carter, who is a politician par excellence <time begin="00:07:07.06"/><clear/>who is very concerned with the poor, very concerned with equity, <time begin="00:07:11.69"/><clear/>and as you all know, won a peace prize. <time begin="00:07:16.56"/><clear/>President Carter, and this is what the Nobel Peace Prize looks like, <time begin="00:07:21.89"/><clear/>aside from the medal, which he won in 2002. <time begin="00:07:26.73"/><clear/> <time begin="00:07:28.37"/><clear/>And here I am with President Carter in Ethiopia about a year ago discussing one <time begin="00:07:32.54"/><clear/>of these interventions related to public health -- <time begin="00:07:34.91"/><clear/>public private public health partnerships involving pills and politics. <time begin="00:07:42.03"/><clear/>Now I really like this statement by President Carter at the award of his Nobel Peace Prize. <time begin="00:07:48.67"/><clear/>He said I was asked to discuss here in Oslo the greatest challenge that the world faces. <time begin="00:07:55.49"/><clear/>Among all the possible choices I decided that the most serious <time begin="00:07:59.27"/><clear/>and universal problem is the growing chasm between the richest and poorest people on earth. <time begin="00:08:06.28"/><clear/>The separation is increasing every year. <time begin="00:08:09.14"/><clear/>The results of this disparity are the root causes of most <time begin="00:08:14.01"/><clear/>of the world's unresolved problems. <time begin="00:08:18.25"/><clear/>So when we talk about today in the next 45 or 50 minutes or so, diseases of poverty, <time begin="00:08:24.50"/><clear/>forgotten diseases and forgotten people, and neglected diseases of the tropics, <time begin="00:08:28.74"/><clear/>we're really not only talking about public health and international or global health, <time begin="00:08:32.65"/><clear/>we're also talking, in my opinion, about global peace. <time begin="00:08:37.52"/><clear/>If you visited the Carter Center in Atlanta, and I hope you will, <time begin="00:08:41.84"/><clear/>you'll know it's a very beautiful place, beautiful grounds. <time begin="00:08:45.40"/><clear/>And on those grounds is what I call my statue. <time begin="00:08:49.35"/><clear/>It is a statue of a young boy leading his blinded father out to the fields for another day <time begin="00:08:56.39"/><clear/>of scratching in the dry earth to earn a living, a way to survive. <time begin="00:09:03.26"/><clear/>These are diseases at the end of the road. <time begin="00:09:07.36"/><clear/>And this little boy is holding a tablet which we must deliver to the end of the road to try <time begin="00:09:14.46"/><clear/>and prevent these conditions and help people. <time begin="00:09:18.80"/><clear/>So what I'm going to be talking about are community-based, integrated MDA, <time begin="00:09:23.80"/><clear/>which stands for Mass Drug Administration programs. <time begin="00:09:28.35"/><clear/>And I'm going speak about it particularly in Nigeria. <time begin="00:09:31.19"/><clear/>And here's the structure of my talk. <time begin="00:09:33.20"/><clear/>I've already given you the introduction. <time begin="00:09:35.99"/><clear/>Now I want to talk a little bit about a few important public health concepts <time begin="00:09:39.37"/><clear/>that will permeate some of the things I'm going to talk about. <time begin="00:09:43.15"/><clear/>Then I'm going talk about three neglected tropical diseases. <time begin="00:09:48.82"/><clear/>RV, which is river blindness, LF, which is lymphatic filariasis, <time begin="00:09:52.66"/><clear/>and Schisto, which is schistosomiasis. <time begin="00:09:54.61"/><clear/>All three are worms, all parasites. <time begin="00:09:58.18"/><clear/>And we're going to talk, then, about Nigeria, <time begin="00:10:00.46"/><clear/>and talk about future challenges for 2008 and beyond. <time begin="00:10:06.09"/><clear/>So first, let's go to concepts. <time begin="00:10:09.68"/><clear/>And the two concepts I want to talk about are control versus elimination strategies. <time begin="00:10:15.89"/><clear/>Sometimes they use the word eradication here. <time begin="00:10:18.92"/><clear/>And vertical versus horizontal public health systems. <time begin="00:10:24.52"/><clear/>So control versus elimination strategies. <time begin="00:10:28.82"/><clear/>Control strategy is one that never ends. <time begin="00:10:33.27"/><clear/>It starts here at the dot and it continues indefinitely into time. <time begin="00:10:40.12"/><clear/>Now that's sort of like our influenza programs. <time begin="00:10:45.53"/><clear/>Every year we should think about getting our influenzae shot. <time begin="00:10:49.66"/><clear/>And we're not imagining a time when we're not going to be getting an influenza shot. <time begin="00:10:54.64"/><clear/>So that's a control program. <time begin="00:10:56.10"/><clear/>It goes on indefinitely. <time begin="00:10:58.08"/><clear/>An elimination program is one that has a beginning and it has an end. <time begin="00:11:02.44"/><clear/>A termination point. <time begin="00:11:04.62"/><clear/>I guess the quintessential elimination or eradication program is small pox. <time begin="00:11:09.15"/><clear/>But we can also think about the effort against polio, <time begin="00:11:11.55"/><clear/>the effort against guinea worm, et cetera. <time begin="00:11:14.99"/><clear/>Next concept. <time begin="00:11:16.67"/><clear/>Vertical versus horizontal public health services. <time begin="00:11:20.63"/><clear/>So a vertical idea is basically a top-down silo driven program. <time begin="00:11:27.92"/><clear/>It's focused, it's controlled, the inputs are only dedicated to that program. <time begin="00:11:34.90"/><clear/>If you buy a vehicle, that vehicle works on that program. <time begin="00:11:37.77"/><clear/>It doesn't work on anything else. <time begin="00:11:39.82"/><clear/>And the out puts are specifically related to the disease or condition that you're after. <time begin="00:11:45.00"/><clear/>And the donors love those kinds of programs. <time begin="00:11:49.63"/><clear/>They also love eradication programs because there's a beginning and an end <time begin="00:11:53.65"/><clear/>and what they call an exit strategy. <time begin="00:11:56.97"/><clear/>Now the horizontal program is more of a polyvalent program. <time begin="00:12:02.84"/><clear/>It's a basket-type program. <time begin="00:12:04.87"/><clear/>It's not a basket case, but it's a basket-type program in the sense that all of the money goes <time begin="00:12:10.06"/><clear/>into one common fund and then there's a decentralized process usually at a district <time begin="00:12:15.18"/><clear/>or a county level where people think about how to spend those monies on priorities. <time begin="00:12:20.74"/><clear/>And the idea is if those programs are more sustainable they need to continue through time, <time begin="00:12:27.13"/><clear/>where the vertical programs usually are more focused and often time-limited. <time begin="00:12:33.21"/><clear/>All of these little arrows indicate all of the little interventions that you can have <time begin="00:12:38.04"/><clear/>in the process of having a polyvalent horizontal public health program. <time begin="00:12:43.99"/><clear/>Immunizations, malaria control, river blindness control, et cetera. <time begin="00:12:49.32"/><clear/>All working through the same structure and the same vehicle, in this case, for example, <time begin="00:12:54.16"/><clear/>would serve a number of different things being sort of a pool or a basket vehicle. <time begin="00:13:00.76"/><clear/>Now if you get to that horizontal condition, what Dr. Hans Remy [Assumed spelling] <time begin="00:13:07.46"/><clear/>at the World Health Organization's tropical disease program says is that integration <time begin="00:13:13.11"/><clear/>of programs means integration of problems. <time begin="00:13:16.77"/><clear/>And some of what I'm going talk about today is how bringing some <time begin="00:13:19.61"/><clear/>of these programs together results in problems and issues. <time begin="00:13:25.41"/><clear/>Okay, so those are the concepts. <time begin="00:13:28.14"/><clear/>Let me move on to talking in a bit of detail <time begin="00:13:30.94"/><clear/>about the three neglected tropical parasitic diseases of the day. <time begin="00:13:35.94"/><clear/>Onchocerciasis, or river blindness, lymphatic filariasis or LF, <time begin="00:13:41.07"/><clear/>and schistosomiasis, which I'll also call schisto. <time begin="00:13:45.23"/><clear/>All three can be controlled by annual dosing of a safe and effective medication. <time begin="00:13:52.79"/><clear/>Along with that annual dosing, it's important that there be health education so people are <time begin="00:13:57.77"/><clear/>on board with understanding what this is all about, have buy-in, <time begin="00:14:01.47"/><clear/>and indeed participation in the activities. <time begin="00:14:04.58"/><clear/>Now the World Health Organization has called 13 diseases neglected tropical diseases. <time begin="00:14:14.50"/><clear/>But gratefully, I'm not going to talk about 13. <time begin="00:14:17.44"/><clear/>The ones that are circled here are the conditions which can be managed <time begin="00:14:21.77"/><clear/>by preventive chemotherapy, or what I call MDA -- mass drug administration. <time begin="00:14:27.37"/><clear/>And of these, I'm only going to speak about a few. <time begin="00:14:31.30"/><clear/>Lymphatic filariasis, onchocerciasis, and schistosomiasis. <time begin="00:14:37.19"/><clear/>Now just a plug for the University of Georgia's Center For Tropical <time begin="00:14:43.76"/><clear/>and Emerging Global Diseases, all of the list here that <time begin="00:14:49.07"/><clear/>have an asterisk next to them are neglected tropical diseases, <time begin="00:14:53.53"/><clear/>and the ones that I underlined, schisto and lymphatic filariasis that are worked on here. <time begin="00:14:58.43"/><clear/>I'm going mention tonight, and I will also mention a little bit about malaria. <time begin="00:15:04.68"/><clear/>Now economists -- health economists have a way of measuring diseases <time begin="00:15:08.84"/><clear/>so they can compare those diseases that kill people with those diseases that maim people. <time begin="00:15:14.56"/><clear/>And the neglected tropical diseases really don't do a lot of killing. <time begin="00:15:18.26"/><clear/>They cause more chronic infections, more debilitating infections. <time begin="00:15:23.10"/><clear/>And when you use what they call, what the economists call DALYs, <time begin="00:15:26.62"/><clear/>which are Disability Adjusted Lost Years, you can compare mortal conditions <time begin="00:15:32.65"/><clear/>with chronic conditions using this scale that I have here. <time begin="00:15:37.86"/><clear/>And what you can see is going from the lowest to the highest, we have some real big players here. <time begin="00:15:42.97"/><clear/>We have tuberculosis, we have malaria, diarrheal, HIV AIDS, and LRI, <time begin="00:15:47.75"/><clear/>which are pneumonias, lower respiratory infections. <time begin="00:15:51.61"/><clear/>And you can see that if you put all the treatable neglected tropical diseases together, <time begin="00:15:55.70"/><clear/>those that can be treated through a mass drug administration program, <time begin="00:15:59.89"/><clear/>you can see that these conditions, as far as their DALYs, rank just above malaria <time begin="00:16:06.10"/><clear/>and just below diarrheal diseases. <time begin="00:16:08.66"/><clear/>So these conditions are in fact quite important in terms of people's lives <time begin="00:16:15.04"/><clear/>and in terms of global morbidity. <time begin="00:16:18.14"/><clear/>Now let's go back to our concept of control versus elimination. <time begin="00:16:26.00"/><clear/>And in this slide we can see that river blindness, onchocerciasis, is a control program. <time begin="00:16:31.16"/><clear/>It goes on basically forever. <time begin="00:16:34.15"/><clear/>Lymphatic filariasis is an elimination program. <time begin="00:16:37.92"/><clear/>It has an effort to treat and then reach a point where treatments will end. <time begin="00:16:43.91"/><clear/>Schistosomiasis is a control program. <time begin="00:16:46.86"/><clear/>Another neglected disease, trachoma is an elimination program. <time begin="00:16:51.15"/><clear/>And each one of these conditions has its own expert committee that looks <time begin="00:16:56.21"/><clear/>on what they're trying to do based on the intricacies of the diseases and come <time begin="00:16:59.65"/><clear/>up with all these series of guidelines that seem to relate when you're talking <time begin="00:17:04.03"/><clear/>about a vertical program, but then become very difficult to integrate when you try <time begin="00:17:08.76"/><clear/>to bring these conditions together. <time begin="00:17:12.04"/><clear/>Let's talk about river blindness. <time begin="00:17:13.37"/><clear/>Here's an old African proverb, nearness to rivers can eat the eyes. <time begin="00:17:19.09"/><clear/>Here's a geographic distribution of river blindness. <time begin="00:17:22.37"/><clear/>Mainly in Africa , but transplanted to the Americas by the slave trade. <time begin="00:17:29.28"/><clear/>So there are programs both in Africa and in the Americas to battle this condition. <time begin="00:17:35.79"/><clear/>It's transmitted by a small black fly that breeds in rapidly flowing streams. <time begin="00:17:40.20"/><clear/>So you find a lot of black flies where the streams have rapids, <time begin="00:17:44.95"/><clear/>because the black flies need highly oxygenated water. <time begin="00:17:48.17"/><clear/>Where you find the black flies, you find the infection. <time begin="00:17:51.65"/><clear/>Now this gentleman is suffering from onchocerciasis, river blindness. <time begin="00:17:57.73"/><clear/>You'll see immediately that he has a lump on his forehead, and that is a nodule. <time begin="00:18:03.28"/><clear/>Then you'll notice he is squinting and his eyes are tearing a bit. <time begin="00:18:06.79"/><clear/>The bright light is affecting him, and he's suffering <time begin="00:18:10.32"/><clear/>from a condition that's actually coming from that nodule. <time begin="00:18:14.52"/><clear/>If I were to take this nodule out and cut it, I would find a worm in it. <time begin="00:18:19.00"/><clear/>This worm is called onchocerca volvulus, and it produces, <time begin="00:18:23.17"/><clear/>males and females are living in this nodule, they produce smaller worms called microfilaria. <time begin="00:18:30.16"/><clear/>You might be able to make out this microfilaria under the microscope here. <time begin="00:18:34.25"/><clear/>The microfilaria is what's picked up by the black fly. <time begin="00:18:38.49"/><clear/>You can see here in this cartoon. <time begin="00:18:40.70"/><clear/>And it also gets into the eyes. <time begin="00:18:43.42"/><clear/>You see little dots here in this person's cornea, and that's an inflammatory reaction <time begin="00:18:48.97"/><clear/>around the microfilaria that have gotten into the eye and are causing problems. <time begin="00:18:53.79"/><clear/>Now I don't know if you can make this out, but over here <time begin="00:19:01.21"/><clear/>we're using a blade to take a little piece of skin out of this person's arm. <time begin="00:19:06.76"/><clear/>That is placed on a microscopic slide and some fluid. <time begin="00:19:09.97"/><clear/>And from that skin will emerge these little worms. <time begin="00:19:14.86"/><clear/>Here you can see one microfilaria, here you can see many. <time begin="00:19:18.15"/><clear/>The more microfilaria you have the worse, the more likely these are able to get into the eye <time begin="00:19:25.00"/><clear/>or cause inflammation such as this. <time begin="00:19:27.61"/><clear/>And what you can see in these eyes, here is white, here at the 6 o'clock position, <time begin="00:19:33.92"/><clear/>where we have what's called sclerosing ceratitis as the inflammation is getting worse. <time begin="00:19:38.62"/><clear/>Here's a microfilaria in the eye. <time begin="00:19:41.02"/><clear/>And in this case, you can see the eye is completely opacified due to the inflammation <time begin="00:19:46.23"/><clear/>that has resulted from the microfilaria being in the eye. <time begin="00:19:49.38"/><clear/>This young man is blind from river blindness. <time begin="00:19:53.49"/><clear/> <time begin="00:19:55.32"/><clear/>Well, 90 million people are at risk of this condition. <time begin="00:19:58.61"/><clear/>It's estimated that 34 million are infected in 37 countries -- 30 of those in Africa. <time begin="00:20:03.96"/><clear/>Some 800,000 people are either blind or severely visually handicapped. <time begin="00:20:08.41"/><clear/>But it's rarely fatal. <time begin="00:20:09.97"/><clear/>The manifestations not only include blindness and visual loss <time begin="00:20:14.55"/><clear/>but terrible skin rashes and awful itching. <time begin="00:20:18.08"/><clear/>The itching is like total body poison ivy. <time begin="00:20:23.12"/><clear/>Here is a young boy leading both a blinded woman and a blinded man through a street by the stick. <time begin="00:20:30.41"/><clear/>Similar to that statue that I showed you that is at the Carter Center. <time begin="00:20:34.98"/><clear/>And here you see an individual who has depigmentation of his shins, <time begin="00:20:39.39"/><clear/>what we call leopard skin, due to the years and years of chronic inflammation <time begin="00:20:43.88"/><clear/>from having these parasites in his skin. <time begin="00:20:46.79"/><clear/>Here is an individual who is both blinded and I think you can make out the shiny shins here <time begin="00:20:53.21"/><clear/>that represents another manifestation of river blindness. <time begin="00:20:58.19"/><clear/>Now Merck and Company developed a medicine called Ivermectin, <time begin="00:21:02.81"/><clear/>brand name Mectizan, which kills the microfilaria. <time begin="00:21:07.67"/><clear/> <time begin="00:21:09.47"/><clear/>Unfortunately, it does not kill the adult worms in those nodules. <time begin="00:21:15.01"/><clear/>So it is not a curative treatment, but it is a treatment that reduces the number <time begin="00:21:18.92"/><clear/>of microfilaria in someone's skin. <time begin="00:21:21.39"/><clear/>If given annually, you basically prevent anyone from going blind and get rid <time begin="00:21:26.29"/><clear/>of the itching and the skin rashes. <time begin="00:21:28.90"/><clear/>So for people who are suffering from these conditions, it's a really great medicine <time begin="00:21:32.58"/><clear/>and people are very, very excited to get it. <time begin="00:21:36.37"/><clear/>President Carter has been involved in this distribution program from the beginning. <time begin="00:21:39.85"/><clear/>Here he is with Roy Vagulos, the chief executive officer of Merck around the time <time begin="00:21:45.53"/><clear/>when the decision for the donation was made. <time begin="00:21:48.20"/><clear/>Here on a visit to Chad. <time begin="00:21:50.19"/><clear/>And this graph shows the growth of the donation program since 1988 <time begin="00:21:56.07"/><clear/>when the distributions began through the year 2006. <time begin="00:22:00.38"/><clear/>Now about 60 million people are being treated per year throughout the world <time begin="00:22:04.98"/><clear/>with this medicine. <time begin="00:22:06.71"/><clear/>The green bar here shows where we need to go. <time begin="00:22:12.43"/><clear/>This is what we call our ultimate treatment goal. <time begin="00:22:14.52"/><clear/>If everyone on the planet was being treated who needs to be treated with Mectizan, <time begin="00:22:19.32"/><clear/>we would need to treat about 90 million people. <time begin="00:22:22.03"/><clear/>The difficulty in moving from these red bars to the final green bar now really relates <time begin="00:22:27.74"/><clear/>to failed states in Africa, places where it's difficult to go because of war <time begin="00:22:32.89"/><clear/>or population displacement, and failed states. <time begin="00:22:37.13"/><clear/>Just quickly, what the Carter Center does is it works in 11 countries. <time begin="00:22:42.60"/><clear/>Six in the Americas, shown here, and five in Africa. <time begin="00:22:47.12"/><clear/>And of course we're going to be focusing our discussion on Nigeria, <time begin="00:22:50.87"/><clear/>and really this little red dot right there. <time begin="00:22:54.39"/><clear/>Here's the Carter Center treatment's curve. <time begin="00:22:57.15"/><clear/>Since the Carter Center began its activities in 1996, <time begin="00:23:02.59"/><clear/>for the last five years we've been treating roughly 10 million people a year <time begin="00:23:07.52"/><clear/>with our partners, the Lions and the ministries of health in the countries where we work. <time begin="00:23:12.96"/><clear/>And in November of 2007 we had a real big milestone <time begin="00:23:16.57"/><clear/>where we celebrated 100 million accumulative treatments with Mectizan <time begin="00:23:21.60"/><clear/>for river blindness, with Ivermectin. <time begin="00:23:24.89"/><clear/>If you're interested, the cost per treatment in Carter Center-assisted programs is about $0.50. <time begin="00:23:31.64"/><clear/>If ranges depending on where we're working, on the infrastructure, and the challenges. <time begin="00:23:36.41"/><clear/>Ranging from about $0.10 per treatment to about $1.50 the value of a dose of the medicine is about $3. <time begin="00:23:43.62"/><clear/>That is what Merck has contributed to this effort. <time begin="00:23:47.50"/><clear/>What I want to show you here is a little bit of impact. <time begin="00:23:52.15"/><clear/>What we have is a cohort or a group of 411 persons in southern Nigeria followed <time begin="00:23:57.68"/><clear/>over an eight-year period, and here's what the impact has looked like. <time begin="00:24:01.91"/><clear/>We've seen nodule rates in this cohort dropping from 60% to under 20%. <time begin="00:24:07.82"/><clear/>Visual impairment dropping from about 17% to about 1%. <time begin="00:24:13.00"/><clear/>And the dermatitis, the itchy rash dropping from about 15% to about 3%. <time begin="00:24:18.56"/><clear/>Very little change in the permanent condition of the leopard skin, but a dramatic impact. <time begin="00:24:25.07"/><clear/>This is a tailor who's reporting to us one of the great stories <time begin="00:24:29.48"/><clear/>that before he started taking medicine he was unable <time begin="00:24:31.87"/><clear/>to thread his needles, and now he's able to do so. <time begin="00:24:36.37"/><clear/>Okay, that's river blindness. <time begin="00:24:37.78"/><clear/>Let me jump to another condition. <time begin="00:24:40.30"/><clear/>Lymphatic filariasis. <time begin="00:24:41.62"/><clear/>Much more widely spread than river blindness. <time begin="00:24:46.45"/><clear/>It's a disease of rural as well as peri-urban poverty. <time begin="00:24:50.69"/><clear/>Over a billion at risk, 120 million people in the world infected in 80 countries. <time begin="00:24:56.16"/><clear/>It is a leading cause of disability. <time begin="00:24:58.38"/><clear/>Some estimates have said the second or third leading cause, globally, of disability. <time begin="00:25:03.21"/><clear/>It is again, like a neglected tropical disease, rarely fatal. <time begin="00:25:08.58"/><clear/>You've all heard of elephantiasis, swollen legs, this is what causes elephantiasis. <time begin="00:25:14.29"/><clear/>A very similar worm to the one that causes river blindness. <time begin="00:25:17.89"/><clear/>Generating microfilaria. <time begin="00:25:19.78"/><clear/>These circulate in the blood. <time begin="00:25:21.30"/><clear/>Here's a microfilaria in the blood. <time begin="00:25:23.24"/><clear/>The adult worms, rather than living in nodules under the skin live in the lymphatics, <time begin="00:25:27.92"/><clear/>and therefore obstruct flow of lymphatic fluid and cause swollen extremities like you see here. <time begin="00:25:35.97"/><clear/>Mosquitos transmit this infection. <time begin="00:25:38.81"/><clear/>They bite, they suck blood, they pick up the parasite, it develops in the mosquitos, <time begin="00:25:44.11"/><clear/>and they transmit it to other people. <time begin="00:25:46.37"/><clear/>Here's an individual with a large leg. <time begin="00:25:50.53"/><clear/>You can see here an ulcer. <time begin="00:25:52.15"/><clear/>Very often these large legs become traumatized, get infected, people suffer from fevers. <time begin="00:25:58.84"/><clear/>And here's a picture from the front of your pamphlet, Nigeria. <time begin="00:26:05.28"/><clear/>Another individual suffering from Nigeria. <time begin="00:26:09.34"/><clear/>Now one thing that's very rarely mentioned but as a matter of fact is even more common <time begin="00:26:14.62"/><clear/>than the large legs is male urogenital disease. <time begin="00:26:18.07"/><clear/>And this individual has fluid in his scrotum, which we call hydrocele. <time begin="00:26:22.38"/><clear/>Can you imagine, guys, carrying that around <time begin="00:26:24.89"/><clear/>in the field all day, working in an agricultural area. <time begin="00:26:29.02"/><clear/>You can also imagine the impact on sexual function and relationships in the family. <time begin="00:26:36.49"/><clear/>And speaking about the female side, here's a young woman who has the face <time begin="00:26:40.69"/><clear/>of lymphatic filariasis, a very sad face. <time begin="00:26:44.74"/><clear/>Because she is unable to be married because of this foot. <time begin="00:26:48.88"/><clear/>And you can see her swollen ankle, and you can also see all of the small incisions made <time begin="00:26:54.52"/><clear/>by traditional healers, local witch doctors, <time begin="00:26:58.11"/><clear/>trying to remove the fluid unsuccessfully from her foot. <time begin="00:27:01.95"/><clear/>Paid for by her mother and her grandmother who really dread the fact that she may never be able <time begin="00:27:07.99"/><clear/>to get married in this traditional society. <time begin="00:27:10.78"/><clear/>There is an effort to completely eliminate this condition. <time begin="00:27:15.25"/><clear/>It's been done in China, it's been almost done in the South Pacific, <time begin="00:27:20.49"/><clear/>and the idea is to use mass drug administration to stop mosquitos from getting infected so <time begin="00:27:27.79"/><clear/>that ultimately no one will have the infection and you can stop treatments. <time begin="00:27:33.07"/><clear/> <time begin="00:27:34.13"/><clear/>The treatment is a combination of the Mectizan which I showed you before. <time begin="00:27:38.33"/><clear/>You might recognize this box down here. <time begin="00:27:40.10"/><clear/>That's the Mectizan box. <time begin="00:27:42.14"/><clear/>Donated by Merck. <time begin="00:27:43.23"/><clear/>And another medicine called Albendazole which is donated <time begin="00:27:46.80"/><clear/>by another large pharmaceutical company, Glaxo Smith Kline, GSK. <time begin="00:27:54.33"/><clear/>These two medicines also happen to be the absolute best medicines that you can give <time begin="00:27:59.02"/><clear/>in combination to knock off intestinal worms. <time begin="00:28:03.07"/><clear/>So what we call S T Hs -- soil transmitted helmiths which is just these big round worms <time begin="00:28:08.52"/><clear/>that you can see here on this map, on this photograph. <time begin="00:28:14.04"/><clear/>These medicines are great for purging people of these worms <time begin="00:28:17.46"/><clear/>and helping with that condition as well. <time begin="00:28:20.14"/><clear/>That's an ancillary benefit. <time begin="00:28:21.82"/><clear/>Health education, washing the legs, another key component. <time begin="00:28:25.49"/><clear/>Health education is key for whatever we do. <time begin="00:28:29.10"/><clear/>Now the third disease I want to tell you about, the third worm, is Schistosomiasis. <time begin="00:28:33.07"/><clear/>There are several different kinds of schistosomiasis. <time begin="00:28:36.99"/><clear/>In Africa there two to consider, particularly here in Nigeria. <time begin="00:28:41.29"/><clear/>And one is called urinary schistosomiasis, and the other is called intestinal schistosomiasis. <time begin="00:28:48.00"/><clear/>Again, schisto is a disease of rural and peri-urban poverty. <time begin="00:28:52.52"/><clear/>Over 650 million people are at risk, 200 million infected, 76 countries. <time begin="00:28:57.91"/><clear/>It has both major and subtle morbidity, and again, rarely fatal, <time begin="00:29:03.47"/><clear/>as neglected tropical diseases are. <time begin="00:29:06.32"/><clear/>Here are the worms. <time begin="00:29:07.75"/><clear/>There's a male worm and a female worm. <time begin="00:29:09.99"/><clear/>The female worm produces eggs. <time begin="00:29:12.70"/><clear/>And these worms actually live in the blood stream, they live in the veins and small veins. <time begin="00:29:18.03"/><clear/>And the egg -- here is an egg here -- has to move across the vein wall, across tissues, <time begin="00:29:23.69"/><clear/>to then exit the body in either urine or feces, <time begin="00:29:26.76"/><clear/>based on whether you have urinary schisto or intestinal schisto. <time begin="00:29:31.55"/><clear/>Once the egg gets into fresh water it will hatch, and this little thing will come <time begin="00:29:37.11"/><clear/>out of it and it will swim around. <time begin="00:29:38.28"/><clear/>It's called a miracidium. <time begin="00:29:39.33"/><clear/>It will invade a snail. <time begin="00:29:41.48"/><clear/>Inside of the snail it will proliferate, and what you see coming <time begin="00:29:44.66"/><clear/>out of this snail are a number of little dots which we call cercariae, <time begin="00:29:49.54"/><clear/>they look something like this if you can see it. <time begin="00:29:51.77"/><clear/>And those burrow into the skin of the next person when they go swimming <time begin="00:29:55.74"/><clear/>or when they are in the water and cause the infection. <time begin="00:29:59.54"/><clear/>Here is a urine microscopic examination of a kid in Mali who has a very, <time begin="00:30:05.31"/><clear/>very heavy urinary schistosomiasis infection. <time begin="00:30:09.96"/><clear/>And here are a bunch of kids in Nigeria all showing little vials containing their urine, <time begin="00:30:16.73"/><clear/>which is very bloody as a result of these eggs coming out in their bladder. <time begin="00:30:21.55"/><clear/>As they come out they cause bleeding. <time begin="00:30:24.45"/><clear/>There are a lot of organ damage that occurs from these eggs, because not all come out. <time begin="00:30:33.25"/><clear/>Some stay in the tissues, like in the bladder, <time begin="00:30:36.35"/><clear/>in the kidneys of the case of urinary schistosomiasis. <time begin="00:30:39.66"/><clear/>In the intestine and in the liver and spleen in the case of intestinal schistosomiasis. <time begin="00:30:45.53"/><clear/>And this causes a lot of issues and a lot of problems and a lot of chronic disease. <time begin="00:30:51.88"/><clear/>This child has a very large abdomen because of his large liver <time begin="00:30:55.97"/><clear/>and spleen resulting from schistosomiasis. <time begin="00:30:59.45"/><clear/>Water contact, everyday activities, of washing, kids swimming. <time begin="00:31:04.98"/><clear/>Because kids in the tropics spend a lot of time in the water kids tend <time begin="00:31:09.41"/><clear/>to be most heavily infected with schisto. <time begin="00:31:12.88"/><clear/>And here is a big tent of the medicine Praziquantel. <time begin="00:31:17.34"/><clear/>A third medicine -- I've told you about Ivermectin, <time begin="00:31:19.55"/><clear/>Mectizan, I've told you about Albendazole. <time begin="00:31:21.45"/><clear/>The third one is Praziquantel. <time begin="00:31:23.51"/><clear/>And this one is being used to treat this kid. <time begin="00:31:26.09"/><clear/>The important thing about Praziquantel is it is a medicine that has not been donated. <time begin="00:31:32.34"/><clear/>So we have to find money to provide treatment for schisto. <time begin="00:31:35.98"/><clear/>At least up until recently. <time begin="00:31:38.33"/><clear/>Here's a child taking her dose of Praziquantel. <time begin="00:31:41.12"/><clear/>Recommended to take the medicine once per year. <time begin="00:31:44.85"/><clear/>We're really talking about annual doses of these medicines to prevent these conditions. <time begin="00:31:51.38"/><clear/>So onchocerciasis is control, lymphatic filariasis is elimination. <time begin="00:31:57.75"/><clear/>Schistosomiasis, control. <time begin="00:31:59.80"/><clear/>Control programs you have to dose people pretty much from now to eternity. <time begin="00:32:04.75"/><clear/>The lymphatic filariasis program is aiming to eliminate, <time begin="00:32:08.41"/><clear/>so at some point we can stop treating. <time begin="00:32:11.30"/><clear/>Okay, that's my background on the three diseases. <time begin="00:32:13.57"/><clear/>Now let's go to a, let's journey to Nigeria and talk a bit about Nigerian programs. <time begin="00:32:18.82"/><clear/>In case you don't know where Nigeria is, here's Africa, there's Nigeria. <time begin="00:32:23.49"/><clear/>West Africa, and here's the capital Abuja, and we're talking about work that's going <time begin="00:32:29.40"/><clear/>on around the city of Jos on the central plateau in the country. <time begin="00:32:35.56"/><clear/>I've worked in Nigeria since 1992. <time begin="00:32:38.36"/><clear/>Had great experiences in Nigeria. <time begin="00:32:40.52"/><clear/>People always hear Nigeria and get freaked out. <time begin="00:32:43.31"/><clear/>But actually in my time there it's been very, very profitable, <time begin="00:32:46.39"/><clear/>great people, great opportunities. <time begin="00:32:48.96"/><clear/>And lots of parasitic diseases. <time begin="00:32:51.93"/><clear/>Here's central Nigeria where our integrated program is ongoing. <time begin="00:32:57.46"/><clear/>And so now let's go into talking a little bit about bundling. <time begin="00:33:00.68"/><clear/>We talked about the neglected diseases. <time begin="00:33:03.16"/><clear/>I'm going to talk about bundling of treatment services. <time begin="00:33:07.56"/><clear/> <time begin="00:33:09.35"/><clear/>Why Nigeria. <time begin="00:33:10.99"/><clear/>Nigeria has the most river blindness in the world. <time begin="00:33:14.37"/><clear/>27 million people in need of treatment. <time begin="00:33:16.85"/><clear/>And it also has the best Mectizan distribution program for river blindness in the world. <time begin="00:33:21.30"/><clear/>A perfect thing, perfect logistical system to start bringing these other conditions <time begin="00:33:26.29"/><clear/>in on top of, because you already have a system that's functioning to integrate with. <time begin="00:33:31.99"/><clear/>Nigeria has the most lymphatic filariasis in Africa. <time begin="00:33:35.69"/><clear/>22% of Nigerians are infected with this parasite. <time begin="00:33:39.45"/><clear/>Nigeria is third globally, after India and Indonesia for this condition. <time begin="00:33:46.72"/><clear/>And for schistosomiasis, Nigeria has the greatest Praziquantel tablet need <time begin="00:33:51.83"/><clear/>of any country in the world. <time begin="00:33:53.38"/><clear/>Including China. <time begin="00:33:55.11"/><clear/>So Nigeria has a lot of parasites and it also has a lot of other diseases <time begin="00:33:59.34"/><clear/>like intestinal worms and trachoma and malaria. <time begin="00:34:01.86"/><clear/>As a matter of fact, with malaria more children, you know, a million children are estimated <time begin="00:34:06.20"/><clear/>to die a year of malaria, and 300,000 of those are Nigerian. <time begin="00:34:10.36"/><clear/>More Nigerian children die a year of malaria than any other nationality. <time begin="00:34:15.54"/><clear/>Here I am in northern Nigeria, outside of the Emir's Palace <time begin="00:34:21.28"/><clear/>with people in their traditional dress. <time begin="00:34:25.42"/><clear/> <time begin="00:34:27.89"/><clear/>Now we published this work back in 2002 and have continued to build on the notion <time begin="00:34:34.32"/><clear/>of lymphatic filariasis elimination, schistosomiasis control, <time begin="00:34:39.49"/><clear/>in combination with onchocerciasis control. <time begin="00:34:43.41"/><clear/> <time begin="00:34:47.44"/><clear/>So river blindness, lymphatic filariasis, and schistosomiasis <time begin="00:34:51.37"/><clear/>through mass drug administration. <time begin="00:34:53.87"/><clear/>Here's a picture of Dr. Abel Eigege who is the director of the activities <time begin="00:34:59.00"/><clear/>in plateau and the Nasarawa states. <time begin="00:35:01.09"/><clear/>And this is how we integrated these three mass drug administration programs at the district <time begin="00:35:07.61"/><clear/>or what we call local government area. <time begin="00:35:10.51"/><clear/>First we built on the river blindness drug administration platform. <time begin="00:35:16.53"/><clear/> <time begin="00:35:17.92"/><clear/>First we had to determine what the conditions were that warranted treatment. <time begin="00:35:23.89"/><clear/>In other words, we had to do something called mapping. <time begin="00:35:27.17"/><clear/>We had to do epidemiological mapping in accord with guidelines of the World Health Organization <time begin="00:35:32.77"/><clear/>to determine where the medicines needed to be given. <time begin="00:35:36.24"/><clear/>We then tailored our distribution training and logistics based on the results <time begin="00:35:41.69"/><clear/>of these mapping exercises, and we implemented community-based treatment <time begin="00:35:46.95"/><clear/>and health education where it was appropriate. <time begin="00:35:49.89"/><clear/>Again, per guidelines. <time begin="00:35:51.45"/><clear/>And we evaluated the impact. <time begin="00:35:53.44"/><clear/>So the concept here in mapping and spacial epidemiology is <time begin="00:35:57.65"/><clear/>that you start off with one platform. <time begin="00:36:00.42"/><clear/>Based on the epi, you build on another disease and another disease, <time begin="00:36:06.09"/><clear/>and even more focal activities across what you find in your disease assessment activities. <time begin="00:36:12.47"/><clear/>Frequently using geographic information systems to help us sort these things out. <time begin="00:36:18.06"/><clear/>So when we started in 1998 our disease mapping for river blindness <time begin="00:36:23.40"/><clear/>in these two states gave us this kind of picture. <time begin="00:36:26.35"/><clear/>Each one of these little segments is a local government area. <time begin="00:36:29.05"/><clear/>This is the equivalent of a county. <time begin="00:36:31.34"/><clear/>And these areas require treatment for river blindness <time begin="00:36:34.67"/><clear/>or onchocerciasis, and these areas did not. <time begin="00:36:37.85"/><clear/>Based on the WHO threshold of having 20% of people in communities having nodules or not. <time begin="00:36:44.59"/><clear/>If you're above 20% you get mass treatment. <time begin="00:36:47.18"/><clear/>If you don't, you don't get mass treatment. <time begin="00:36:51.66"/><clear/>This graphic shows the impact between 1992 <time begin="00:36:56.57"/><clear/>when we started the program, a 52% prevalence in these areas. <time begin="00:37:01.02"/><clear/>Dropping to 2.9% by the year 2000 due to the impact of medicine and the treatment. <time begin="00:37:07.19"/><clear/>Now you might have trouble making some of this out, but I just want you to take a look <time begin="00:37:11.23"/><clear/>at this mapping exercise for lymphatic filariasis in the same area <time begin="00:37:15.59"/><clear/>which we conducted around the year 1999. <time begin="00:37:18.71"/><clear/>And the point is that the threshold for mass treatment for lymphatic filariasis is 1%. <time begin="00:37:24.92"/><clear/>1% of infection using a rapid diagnostic test. <time begin="00:37:29.69"/><clear/>And you can see just looking next to these names of villages <time begin="00:37:33.54"/><clear/>that all of these numbers are over 1%. <time begin="00:37:35.86"/><clear/>As a matter of fact, there's only one 0 here in this entire map. <time begin="00:37:41.21"/><clear/>Which basically told us that unlike oncho, we had to treat state-wide <time begin="00:37:45.38"/><clear/>in all of the 30 local government areas <time begin="00:37:47.80"/><clear/>for lymphatic filariasis and the program had to expand. <time begin="00:37:51.15"/><clear/>So the map looks like this now, after the mapping. <time begin="00:37:54.36"/><clear/>These areas are both oncho and LF, and these areas are LF alone. <time begin="00:38:00.11"/><clear/>And this is how it looked. <time begin="00:38:02.54"/><clear/>We started out with mass treatment in 1992 treating about half a million people per year. <time begin="00:38:09.03"/><clear/>In 2000, we launched the program in a few local government areas to add Albendazole <time begin="00:38:15.30"/><clear/>for lymphatic filariasis in combination treatment. <time begin="00:38:18.66"/><clear/>Now you're hitting two diseases. <time begin="00:38:20.76"/><clear/>We grew to the entire oncho area by 2001, <time begin="00:38:25.01"/><clear/>and then expanded up to 3 million treatments per year to reach everyone for lymphatic filariasis <time begin="00:38:31.37"/><clear/>in those other districts by the year 2003. <time begin="00:38:35.77"/><clear/>And what happened was we moved from an oncho platform to now a much broader, <time begin="00:38:42.49"/><clear/>by the year 2003, lymphatic filariasis platform. <time begin="00:38:47.14"/><clear/>And LF became our platform program with which to hang other activities. <time begin="00:38:53.50"/><clear/>This is just a graphic which shows how our treatments look through 2007. <time begin="00:38:58.50"/><clear/>Combined LF and oncho treatments with Ivermectin and Albendazole. <time begin="00:39:02.54"/><clear/>About three-and-a-half million people being treated per year. <time begin="00:39:05.65"/><clear/>And that was really pretty easy. <time begin="00:39:07.90"/><clear/>Integration of lymphatic filariasis with river blindness was fast and easy. <time begin="00:39:12.85"/><clear/> <time begin="00:39:13.88"/><clear/>And what we're trying to do, however, is to eliminate lymphatic filariasis. <time begin="00:39:19.72"/><clear/>The impact has been great. <time begin="00:39:21.18"/><clear/>These are showing between the year 2000 and the year 2004, the drop in our antigen tests, <time begin="00:39:27.91"/><clear/>our infection rates in humans from 45% to 10%. <time begin="00:39:32.03"/><clear/>Our infection rate of the parasite in mosquitos, from 5% to 1%. <time begin="00:39:36.76"/><clear/>An analysis last year showed this has gone down even further <time begin="00:39:40.05"/><clear/>to about half a percent infection rate in mosquitos and 5% infection rates in people. <time begin="00:39:44.85"/><clear/>We're getting close to eliminating this infection. <time begin="00:39:48.88"/><clear/>And to come back to that original graphic, if you recall here's our oncho control arrow <time begin="00:39:54.45"/><clear/>up at the the top which needs to go on forever. <time begin="00:39:57.57"/><clear/>That's the red bar treatments that seem to have to keep marching on ad infinitum. <time begin="00:40:02.69"/><clear/>And here is our lymphatic filariasis platform which we hope will be able <time begin="00:40:06.97"/><clear/>to stop our treatments in 2008 or 2009. <time begin="00:40:10.64"/><clear/>And so when we talk about integrating programs we have to think about in two <time begin="00:40:15.84"/><clear/>or three years what happened to our platform that we're integrating into. <time begin="00:40:20.79"/><clear/>So a lot of people like to talk about the lymphatic filariasis <time begin="00:40:25.32"/><clear/>and the onchocerciasis program since they both use this medicine Ivermectin <time begin="00:40:29.08"/><clear/>as the twin programs, and they're easy to integrate. <time begin="00:40:32.25"/><clear/>But actually when you think about one being an elimination program <time begin="00:40:35.14"/><clear/>and one being a control program it gets a little bit more difficult <time begin="00:40:39.18"/><clear/>to imagine how that's going to continue in the future. <time begin="00:40:43.10"/><clear/>My daughter Alex is in the audience. <time begin="00:40:45.21"/><clear/>She's a freshman at the UGA. <time begin="00:40:47.13"/><clear/>This is a snail drawing she did when she was about 8. <time begin="00:40:51.02"/><clear/>Let's talk a little bit about schistosomiasis. <time begin="00:40:54.66"/><clear/>I think she wants to be an art major here at UGA. <time begin="00:40:57.42"/><clear/>You can use that in your portfolio I know you're getting together. <time begin="00:41:04.59"/><clear/>Really, schistosomiasis is like Thing 1 and Thing 2. <time begin="00:41:07.89"/><clear/>They're really quite different programs compared to what I have been showing you. <time begin="00:41:13.24"/><clear/>Even though in 2007 we celebrated 1 million treatments with Praziquantel. <time begin="00:41:18.50"/><clear/>Remember, we have to find money to buy these treatments. <time begin="00:41:21.93"/><clear/>And it costs about $0.20 to treat a child with this medicine. <time begin="00:41:25.88"/><clear/>And when you start talking about treating a million people, that becomes real money. <time begin="00:41:30.21"/><clear/>So the integration of schisto with Praziquantel to the lymphatic filariasis <time begin="00:41:37.17"/><clear/>and river blindness programs with Ivermectin/Albendazole has been problematic <time begin="00:41:41.49"/><clear/>and it's been slow. <time begin="00:41:43.25"/><clear/>Getting at these kids is difficult. <time begin="00:41:46.49"/><clear/>Now urinary schistosomiasis, our approach <time begin="00:41:49.52"/><clear/>to urinary schistosomiasis has been relatively easy compared to the other form <time begin="00:41:55.83"/><clear/>of schistosomiasis that occurs in Nigeria, intestinal schistosomiasis. <time begin="00:42:00.19"/><clear/>In urinary schistosomiasis we can use what we call reagent dip stick. <time begin="00:42:04.18"/><clear/>You just dip it into someone's urine, and even if it's not grossly bloody it will turn colors <time begin="00:42:09.65"/><clear/>to indicate there's blood in the urine, which in this case is basically synonymous with infection <time begin="00:42:14.65"/><clear/>with schistosomiasis, urinary schistosomiasis. <time begin="00:42:17.62"/><clear/>So we can use this to map. <time begin="00:42:20.75"/><clear/>We also can use this to evaluate the program, and we know that within two years <time begin="00:42:24.79"/><clear/>of treating kids with Praziquantel the blood in the urine drops dramatically. <time begin="00:42:29.75"/><clear/>Take a look at these two sentinal villages. <time begin="00:42:32.09"/><clear/>Mungkohot and Timjim, which started off here in Timjim with about 50% <time begin="00:42:36.87"/><clear/>of kids infected or with blood in their urine. <time begin="00:42:39.47"/><clear/>Here in Mungkohot, 80% with blood in their urine. <time begin="00:42:42.54"/><clear/>These are the 95% confidence intervals. <time begin="00:42:45.34"/><clear/>And within two years these numbers had dropped to well below 10%. <time begin="00:42:51.71"/><clear/>Dramatic impact. <time begin="00:42:53.28"/><clear/>But intestinal schistosomiasis is much more difficult. <time begin="00:42:56.87"/><clear/>Because to get at that, to be able to map that we have to collect stools. <time begin="00:43:00.99"/><clear/>You have to go and ask kids to go defecate and bring their feces back to you. <time begin="00:43:06.57"/><clear/>Then you have to carry them back to the lab in a short period of time. <time begin="00:43:09.67"/><clear/>You go through a very smelly procedure of preparing what we call a Kato-Katz test, <time begin="00:43:14.66"/><clear/>and then you have to look at these under the microscope a few inches from your nose. <time begin="00:43:22.19"/><clear/>Now a big development last year was the first big donation by another Merck, <time begin="00:43:29.68"/><clear/>this is the German Merck called E. Merck, of Praziquantel. <time begin="00:43:33.47"/><clear/>And this was a really big development <time begin="00:43:35.72"/><clear/>where E. Merck said they would give the World Health Organization 200 million tablets <time begin="00:43:41.88"/><clear/>over a 10-year period to promote the use or the control of schistosomiasis. <time begin="00:43:49.41"/><clear/>And at our Nigeria program review in 2007, the World Health representative here <time begin="00:43:57.35"/><clear/>at the opening session pledged 1.5 million tablets of Praziquantel <time begin="00:44:03.30"/><clear/>to Carter Center assisted programs in Nigeria, beginning this year. <time begin="00:44:07.74"/><clear/>It's to be targeted at school-age kids. <time begin="00:44:10.82"/><clear/>And the tablets are now in the Port of Lagos and we're working <time begin="00:44:14.01"/><clear/>to get them out and start our activities. <time begin="00:44:16.66"/><clear/>So that's a real breakthrough. <time begin="00:44:19.80"/><clear/>Back in the year 2006 I wrote an article with colleagues about how difficult it was <time begin="00:44:26.03"/><clear/>to integrate schistosomiasis with other mass drug programs. <time begin="00:44:29.93"/><clear/>And the three points in that article were the challenges were the cost of Praziquantel, <time begin="00:44:35.55"/><clear/>the cost of extra treatment rounds -- <time begin="00:44:37.69"/><clear/>because at that point in time we could not give the Praziquantel together with the other medicines, <time begin="00:44:42.50"/><clear/>so we had to make another trip to the villages for treatment. <time begin="00:44:45.10"/><clear/>And then the cost of mapping. <time begin="00:44:48.99"/><clear/>Well the cost of Praziquantel now in our situation in these areas has been solved. <time begin="00:44:54.82"/><clear/>The cost of extra treatment rounds has also had a major development. <time begin="00:44:58.79"/><clear/>There have been some studies looking at the Pharmical-kinetics, the drug-drug interaction <time begin="00:45:03.55"/><clear/>of Praziquantel with the other medicines Ivermectin and Albendazole, <time begin="00:45:07.75"/><clear/>and it's been discovered that these medicines can be given together. <time begin="00:45:11.21"/><clear/>There's no danger in giving these medicines together. <time begin="00:45:14.31"/><clear/>And just in 2008 there's a report of what we call triple drug administration, <time begin="00:45:19.80"/><clear/>triple co-administration of these three drugs in Zanzibar. <time begin="00:45:22.97"/><clear/>Over 700,000 people safely treated. <time begin="00:45:26.41"/><clear/>And indeed in Nigeria last year, we did a smaller study, <time begin="00:45:30.41"/><clear/>in 5,000 people, safely administering three drugs without any problems. <time begin="00:45:35.84"/><clear/>That study is now in press. <time begin="00:45:38.42"/><clear/>So we can treat all three diseases at the same time. <time begin="00:45:42.82"/><clear/>It's a lot of pills. <time begin="00:45:44.58"/><clear/>These are the tablets that a tall individual would have to take. <time begin="00:45:48.62"/><clear/>What you're seeing here is you would have to swallow five Praziquantel tablets, <time begin="00:45:52.86"/><clear/>four Mectizan tablets, and one Albendazole tablet. <time begin="00:45:56.99"/><clear/>It's a handful of medicines. <time begin="00:46:00.24"/><clear/>But it is solving our issue of extra treatment rounds. <time begin="00:46:04.40"/><clear/>What about the costs of mapping. <time begin="00:46:08.10"/><clear/>Well, the WHO approach to mapping uses children <time begin="00:46:11.26"/><clear/>as what we call indicator groups to decide what you need to do. <time begin="00:46:14.87"/><clear/>In other words, you would go to a village, you'd go to a school, <time begin="00:46:17.88"/><clear/>you get a bunch of kids together, and you would test them <time begin="00:46:20.61"/><clear/>for either urinary or intestinal schistosomiasis. <time begin="00:46:23.96"/><clear/>And if 50% of the kids were infected you would need to go and treat the entire population. <time begin="00:46:30.67"/><clear/>And if 20 to 49% of those kids that you tested were infected you would only need <time begin="00:46:34.80"/><clear/>to treat all the school-age kids in that community. <time begin="00:46:37.50"/><clear/>If less than 20% were infected you would not do a mass drug administration in that program. <time begin="00:46:43.38"/><clear/>Imagine, one out of five kids infected and you wouldn't do a mass drug administration. <time begin="00:46:47.97"/><clear/>But those were the guidelines. <time begin="00:46:49.95"/><clear/>And this is a graphic that summarized testing of 22,000 kids in 747 villages. <time begin="00:46:57.61"/><clear/>A big effort to look at dip sticks in the urine. <time begin="00:47:01.06"/><clear/>How many kids had blood in the urine, how many communities would warrant treatment. <time begin="00:47:05.12"/><clear/>And it works out like this. <time begin="00:47:06.26"/><clear/>Of 747 communities tested, about half of those require some sort <time begin="00:47:13.48"/><clear/>of mass treatment with Praziquantel. <time begin="00:47:15.22"/><clear/>And of that group, two-thirds required just treating school children <time begin="00:47:20.73"/><clear/>and one-third require us treating the entire community. <time begin="00:47:23.53"/><clear/>It becomes very complicated and when you start mapping this out on top of our platforms, <time begin="00:47:29.71"/><clear/>as I showed you before, the map gets even more complicated <time begin="00:47:33.98"/><clear/>as we try and move this program along. <time begin="00:47:36.94"/><clear/>But what kept me up at night was wondering <time begin="00:47:40.29"/><clear/>about intestinal schistosomiasis which we can't test for. <time begin="00:47:44.36"/><clear/>And we're running around and we've said, oh, well half of the villages don't need Praziquantel <time begin="00:47:47.97"/><clear/>because they don't have urinary schistosomiasis. <time begin="00:47:50.74"/><clear/>And the question was, well, how many <time begin="00:47:52.12"/><clear/>of those villages we're not treating really should be treated with Praziquantel <time begin="00:47:56.07"/><clear/>because they have the other form of schistosomiasis. <time begin="00:47:58.93"/><clear/>So in a very important study we did in 2006 done <time begin="00:48:01.93"/><clear/>by Dr. Julie Gutman an infectious disease fellow at Emory, <time begin="00:48:06.04"/><clear/>she looked at what we called missed treatment opportunities for intestinal schistosomiasis, <time begin="00:48:11.32"/><clear/>which we call schistosomiasis mansoni. <time begin="00:48:13.78"/><clear/>And this is what she did. <time begin="00:48:16.46"/><clear/>She looked at the group of communities circled here which we'd been to, we assessed, <time begin="00:48:22.15"/><clear/>and we said they don't need schisto treatment because they don't have urinary schistosomiasis. <time begin="00:48:26.22"/><clear/>And she sampled a number of villages from this group. <time begin="00:48:30.43"/><clear/>And she tested 924 kids. <time begin="00:48:32.83"/><clear/>Here are some kids coming, carrying their stool specimens on their heads from the night before. <time begin="00:48:38.56"/><clear/>And lo and behold, she found that 25% <time begin="00:48:41.03"/><clear/>of these kids had intestinal schistosomiasis that were not being treated. <time begin="00:48:45.02"/><clear/>And if we looked by WHO guidelines at the community level using these kids <time begin="00:48:50.33"/><clear/>as an indicator group, of the 50% of communities not needing treatment <time begin="00:48:54.90"/><clear/>for urinary schistosomiasis, over half of those needed <time begin="00:48:58.50"/><clear/>to be treated for intestinal schistosomiasis. <time begin="00:49:00.58"/><clear/>So we're running around doing all this mapping, which overall 80% of the communities needed <time begin="00:49:05.39"/><clear/>to be treated for some form of schistosomiasis. <time begin="00:49:08.14"/><clear/>And my question is why are we spending this money and why are we doing this. <time begin="00:49:11.19"/><clear/>Why don't we just treat everybody. <time begin="00:49:13.78"/><clear/>So the cost of mapping is also falling off of our list <time begin="00:49:17.44"/><clear/>and we're moving toward a much broader treatment program for schistosomiasis. <time begin="00:49:21.98"/><clear/>And we've got new ideas now for new resources in 2008, or to quote Ralph Waldo Emerson, <time begin="00:49:28.70"/><clear/>we need to simplify, simplify, simplify. <time begin="00:49:32.28"/><clear/>So we're using our new donation this year to treat all school-age kids <time begin="00:49:37.65"/><clear/>in plateau and Nasarawa. <time begin="00:49:39.82"/><clear/>We're going to use triple drug administration. <time begin="00:49:42.87"/><clear/>That means we'll give all three medicines at once. <time begin="00:49:45.29"/><clear/>But only to the school-age kids will they get Praziquantel. <time begin="00:49:48.20"/><clear/>So they won't have too much of a handful. <time begin="00:49:49.91"/><clear/>It will be two extra tablets. <time begin="00:49:53.04"/><clear/>We'll get it done in a single round, we'll be less focused on mapping results, <time begin="00:49:57.38"/><clear/>and we'll forgo community-wide treatment with Praziquantel. <time begin="00:50:00.62"/><clear/>Now we're only focusing on kids in our mass treatment program. <time begin="00:50:06.01"/><clear/>This is a curve of how our treatments have looked since 1999 with Praziquantel. <time begin="00:50:11.71"/><clear/>At most 200,000 treatments per year. <time begin="00:50:14.86"/><clear/>And this is what we're going to do this year. <time begin="00:50:17.52"/><clear/>We're aiming to treat a million, and this is a big challenge. <time begin="00:50:20.96"/><clear/>The medicine's in the port, and we're going start doing this very soon. <time begin="00:50:25.39"/><clear/>Let me conclude on my Nigeria piece. <time begin="00:50:28.68"/><clear/>Integrating LF and river blindness programs at the district level was comparatively easy. <time begin="00:50:34.63"/><clear/>LF took over from the river blindness as a platform program due to its size. <time begin="00:50:39.45"/><clear/>But this elimination strategy will mean we'll lose the platform sometime in 2008, <time begin="00:50:44.61"/><clear/>and what will we do, woe is us if that happens. <time begin="00:50:48.06"/><clear/>Conclusions related to river blindness. <time begin="00:50:50.15"/><clear/>Well, the integration was difficult <time begin="00:50:52.06"/><clear/>because Praziquantel was not donated, it cost a lot of money. <time begin="00:50:55.91"/><clear/>We had to do a lot of assessments. <time begin="00:50:57.84"/><clear/>The mapping took a long time. <time begin="00:50:59.30"/><clear/>Some communities were don't treat, some were treat everyone, <time begin="00:51:02.45"/><clear/>some were treat just school-age children. <time begin="00:51:04.18"/><clear/>It really complicated our lives. <time begin="00:51:06.41"/><clear/>And the delivery of Praziquantel had to be as a separate dose. <time begin="00:51:10.06"/><clear/>And now we've gotten around all of that and we're going for 1 million treatments in 2008. <time begin="00:51:16.82"/><clear/>Let me try to wind up with some of the future challenges. <time begin="00:51:20.37"/><clear/>We talked a lot about bundling and neglected diseases, <time begin="00:51:23.70"/><clear/>but grass roots services is a key element that I didn't talk about. <time begin="00:51:28.46"/><clear/>And I wanted to point out the way we do this is through fostering partnerships <time begin="00:51:33.96"/><clear/>at the community level and using community volunteers in these programs. <time begin="00:51:38.76"/><clear/>It is those volunteers who are responsible for picking the medicine up at a central location <time begin="00:51:44.65"/><clear/>and getting it to the end of the road. <time begin="00:51:47.55"/><clear/>This mobile distribution business is not sustainable. <time begin="00:51:51.82"/><clear/>What's sustainable is a community volunteer with a Chinese bicycle. <time begin="00:51:56.00"/><clear/>And I think you can imagine that when infrastructure looks like this and your pergero stops <time begin="00:52:01.97"/><clear/>at that bridge, you can imagine the volunteer, he or she picking up her bicycle and foraging <time begin="00:52:09.79"/><clear/>that stream, getting on and carrying on with the tablets for the community. <time begin="00:52:15.26"/><clear/>That means people really have to understand what this is about. <time begin="00:52:19.33"/><clear/>They not only have to buy in but they have to understand how to direct these programs <time begin="00:52:24.39"/><clear/>and get the medicines out in a safe and effective manner. <time begin="00:52:28.89"/><clear/>This is community-based, not facility-based. <time begin="00:52:32.44"/><clear/>We're not looking for outreach from local health centers. <time begin="00:52:36.32"/><clear/>Community people are doing this. <time begin="00:52:38.49"/><clear/>And to quote Mark Twain, that's the difference between government and individuals. <time begin="00:52:43.06"/><clear/>Governments don't care, individuals do. <time begin="00:52:45.90"/><clear/>And our focus has been on the very strong traditional kinship clan system <time begin="00:52:53.52"/><clear/>to distribute medicines to family and blood relatives. <time begin="00:52:57.90"/><clear/>This is something that in these traditional systems is an obligation <time begin="00:53:02.19"/><clear/>when people are convinced that this is important to their health. <time begin="00:53:04.70"/><clear/>It's a joyful obligation. <time begin="00:53:06.63"/><clear/>And I've worked a lot with an anthropologist from Uganda Dr. Moses Katabarwa, <time begin="00:53:11.63"/><clear/>in developing this distribution system where we found very closely that the communities <time begin="00:53:17.12"/><clear/>that tended to succeed in distribution of these medicines are those based on blood relationships <time begin="00:53:23.33"/><clear/>and blood distribution, clan distribution systems. <time begin="00:53:26.19"/><clear/>And the ones that don't are the ones that don't take advantage of those great African systems. <time begin="00:53:32.64"/><clear/>Well now we're in the midst of a new Bill and Melinda Gates Foundation grant on integration. <time begin="00:53:37.45"/><clear/>The Bill and Melinda Gates Foundation wants us to cost all of this out. <time begin="00:53:41.41"/><clear/>That whole DALY thing. <time begin="00:53:42.76"/><clear/>They're very interested in this hypothesis. <time begin="00:53:46.29"/><clear/>Community-based disease control programs increase the effectiveness and reduce cost. <time begin="00:53:51.54"/><clear/>Easing the strain on these horizontal public health systems of the African countries. <time begin="00:53:56.35"/><clear/>Integration will improve health of as many people as possible at a cost <time begin="00:54:00.10"/><clear/>that can be sustained for as long as necessary. <time begin="00:54:03.43"/><clear/>Kind of a tough, testable hypothesis, but that's what we're in the midst of doing right now <time begin="00:54:07.73"/><clear/>in collaboration with CDC and Emory economists. <time begin="00:54:11.98"/><clear/>And we're also involved in using the same system to distribute long-lasting insecticidal bed nets <time begin="00:54:17.73"/><clear/>because they are an injunctive tool to use against lymphatic filariasis as we try <time begin="00:54:25.88"/><clear/>to eradicate lymphatic filariasis because mosquitos transmit that parasite. <time begin="00:54:31.15"/><clear/>So treating as well as providing bed nets gives us two tools against that condition. <time begin="00:54:38.09"/><clear/>The last thing we're going to look in to is going to be another drug donation program <time begin="00:54:43.89"/><clear/>against trachoma, a blinding disease. <time begin="00:54:46.40"/><clear/>This is a bacterium so I'm not going to talk about it. <time begin="00:54:49.30"/><clear/>But Pfizer is donating a medicine called Azithromycin, which can in three rounds, <time begin="00:54:55.98"/><clear/>three annual treatments if done right can probably eliminate blinding trachoma <time begin="00:55:01.12"/><clear/>in these places. <time begin="00:55:03.14"/><clear/>Well, so I've talked about bundling, I've talked about grass roots services, <time begin="00:55:07.79"/><clear/>I've talked about battling neglected tropical diseases, and we have journeyed to Africa. <time begin="00:55:12.34"/><clear/>I want to thank a bunch of people, government, villages, University of Jos, CDC, Emory, <time begin="00:55:18.63"/><clear/>the Gates Foundation, the pharmaceutical companies, Merck, GSK, and I hope soon E. Merck <time begin="00:55:24.34"/><clear/>when we get the medicine out of Lagos. <time begin="00:55:26.17"/><clear/>Praziquantel, Izumi, the Lions, the World Bank, APOC, The African Programme for Oncho Control, APOC, <time begin="00:55:32.51"/><clear/>and I just wanted to give one, <time begin="00:55:36.45"/><clear/>two reflections for the students here about tropical diseases <time begin="00:55:40.80"/><clear/>as you climb the mountain toward your career. <time begin="00:55:45.53"/><clear/>Very important person in my medical school career, Dr. Ben Kean. <time begin="00:55:51.26"/><clear/>Great American tropical disease specialist said the following <time begin="00:55:56.98"/><clear/>in his article "Never Go Back the Way You Came.": <time begin="00:56:01.55"/><clear/>"When a student asks me today about going into tropical medicine, I tell him or her this. <time begin="00:56:06.69"/><clear/>Decide what field you want to go into, master the specialty. <time begin="00:56:11.06"/><clear/>Then when you go to the tropics you can bring special knowledge with you. <time begin="00:56:15.48"/><clear/>The basis for eventual success in tropical medicine is temporary restraint <time begin="00:56:20.70"/><clear/>of your enthusiasm." <time begin="00:56:22.65"/><clear/>We all know that you guys are very enthusiastic. <time begin="00:56:25.97"/><clear/>So to quote from another great public health figure, <time begin="00:56:29.98"/><clear/>Dr. William Foege, former director of CDC. <time begin="00:56:33.28"/><clear/>I encourage you all while you're tempering your enthusiasms in studying <time begin="00:56:37.57"/><clear/>to don't forget to be globalists. <time begin="00:56:40.04"/><clear/>Be activists. <time begin="00:56:42.03"/><clear/>If you're looking at science, try to be practical scientists. <time begin="00:56:45.51"/><clear/>Look for simple solutions. <time begin="00:56:47.26"/><clear/>Be confident and be focused. <time begin="00:56:51.47"/><clear/>It has great rewards, like these chickens that I routinely get in Nigeria. <time begin="00:56:57.36"/><clear/>So it was a great pleasure to come here. <time begin="00:56:59.93"/><clear/>I'm really pleased that my daughter is a bulldog and maybe I'm a bulldog, too. <time begin="00:57:04.27"/><clear/>And congratulations, and thank you very much. <time begin="00:57:08.51"/><clear/>[ Applause ] <time begin="00:57:17.50"/><clear/> </center> </window>

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