The building behind the light-blue iron gate is not elegant by modern architectural standards, but it is a repository of several decades of scientific knowledge that has brought hope and future to millions of the poor in hard-to-reach communities afflicted with myriad diseases in Africa, especially river blindness. The six-block complex, including four bungalows and a two-storey structure, houses the Onchocerciasis Control Programme (OCP) in West Africa, the Phase I of the control programme, and it is now the headquarters of the WHO African Programme for Onchocerciasis Control (APOC), its Special Intervention Zones (SIZ) , and the Multi-Disease Surveillance Centre (MDSC).
On a normal day, the complex is a melting pot of activities and a laboratory of ideas, with scientists and researchers, administrative and technical staff busy on a legion of tasks including the analysis of statistics and data collected from field trips. All of these efforts drive disease control projects in a continent struggling under a disproportionately high disease burden. It is from this building that Africa, with the support of the international donor community, has been fighting onchocerciasis (river blindness) for more than 30 years, first through OCP, and now APOC (Phase II) of the control programme. And from her office on the first floor of the main building, Nigerian scientist, Dr. Uche Veronica Amazigo, has been calling the shots as the Programmes' first female Director from 2005. APOC was founded in 1995, and effectively took over from where OCP left off in 2002, but with an expanded mandate to replicate the OCP successes in 19 other African river blindness-endemic countries and, this time, using ivermectin as the only control tool. Given the enormity of its mandate, APOC in 1997 devised a new strategy - the Community-Directed Treatment with ivermectin (CDTi), now called the community-directed intervention (CDI) approach, to deal with the stubborn disease caused by worms and transmitted by the black fly.
Indisputably, the CDTi strategy has been a remarkable success and, in the last three years, the mammoth challenge of steering APOC towards its ambitious target of eliminating river blindness as a public health disease in Africa by 2015 has fallen on the broad shoulders of Amazigo, a fire-brand professional who is no stranger to the complexities of scientific research and health administration, having served in APOC for more than 10 years in different capacities, including as Chief of the Sustainable Drug Distribution Unit. Indeed, for this former Senior lecturer on tropical diseases at the well-respected University of Nigeria in the eastern city of Nsukka, anti-river blindness drive is a passion, heightened by her chance encounter in 1991 with a pregnant woman plagued by the disease's itchy lesions and depigmentation. As it is common with many onchocerciasis patients, the disfiguring effects brought stigmatisation and had, in the case of this pregnant woman at an antenatal clinic in eastern Nigeria, resulted in her husband abandoning her. Amazigo resolved to help the woman pay for her treatment and to learn more about the human devastation of onchocerciaisis.
In a sense, Amazigo can stake a valid claim to the APOC brand, process and philosophy, for it was the result of her research with a WHO grant that formed the scientific basis for the launch of APOC in 1995.
The revolutionary outcome of that research has not only changed international perceptions about onchocerciasis morbidity, WHO has replicated it in a number of countries. A member of the Consultative Group on Women's Health for the 1993 World Development Report, one eloquent testimony to Amazigo's well-documented work in communication, advocacy, community mobilisation and partnership is the UNFPA-UNIFEM-sponsored film "Broken Wings," which she produced for the World Conference on Women in Beijing 1995. The 2005 nominee for the Global Champion of Health award by the US WGGH/NOVA Science has also produced and edited several training modules, with her works appearing in international publications, including the American Journal of Tropical Medicine and Hygiene, the medical health journal Lancet and the Annals of Tropical Medicine and Parasitology. In a long distinguished career of public service, involving extensive travelling to remote parts of Africa - from mountainous villages in Cameroon to rural Uganda, to hamlets in the thick forests of the two Congos to villages in Southern Sudan - Amazigo, a humble beginner from a well-to-do family, derives great joy from spending quality time with poor communities, catering to their needs and mobilising support and resources on their behalf at international fora.
Before she assumed the leadership of APOC, the two control programmes, OCP and APOC had between them seen five male directors, including two European pioneer directors. Gambian surgeon Ebrahim Malick Samba, the first African to head the OCP from 1981, left in 1994 to assume the directorship of the WHO Regional Office for Africa. An elegant, unassuming, highly disciplined and deeply religious woman in her 50s, Amazigo has been credited with bringing a dynamic leadership to APOC and health administration in general in Africa. Combining a persuasive and accommodating disposition with an infectious determination and dedication to duty, she is equally praised for inspiring confidence among colleagues and motivating them to higher levels of achievement. APOC Programme Manager/Coordinator, Dr. Laurent Yameogo, said of for Amazigo: "Community service, especially river blindness control, is a passion and helping the poorest of the poor," almost a vocation. "Her persuasive character makes her a great mobiliser of people and resources and one of her strongest points is that she believes in the strength of others," said Yameogo, who stressed that Amazigo exudes boundless energy with a motivating and charismatic aura about her. In her carriage, comportment and general character and even simple dressing style, she epitomises the best in the professional African woman.
As she fielded questions from a group of journalists that attended the just-ended WHO international conference on Primary Health Care in Ouagadougou, the APOC director displayed the versatility of a seasoned administrator, a humanist, a mother, a teacher and a good listener. Though soft-spoken, Amazigo - also a stickler for details - will not hesitate to raise her voice, especially to drive home any point she feels strongly about. Her colleagues and subordinates describe her as "a workaholic" who is always striving for excellence with exemplary result-oriented work ethics. Her admirers call her an "African Amazon" and "a general who commands from the front line." Dr. Mounkaila Noma, APOC Chief of Epidemiology and Vector Elimination Unit, who has worked with Amazigo for 11 years, said she relates to colleagues as a "sister." "She has an obsession for deadline and innovation that will bring positive changes," Noma said. "Dr. Amazigo believes in rendering service to poor communities across the road."
According to him: "she is a team player who believes in capacity-building both at country level and within the organisation, and she will always insist on results from every member of the team, be they yellow, white or black." Her secretary of many years, Mrs. Patricia Mensah, said Amazigo "knows her onions and believes in community service." Under Amazigo and her team, APOC's reputation and international visibility is on the ascendancy. As reward for its string of successes, the programme is riding on the crest of a strong broad-based partnership involving 19 African countries, 20 donor countries and institutions, UN agencies, 12 Non-Governmental Development Organisations (NGDOs), a number of local Non-Governmental Organisations (NGOs) and a free donation of ivermectin by Merck Co Inc for as long as the drug would be needed.
But in her disarming modesty, Amazigo claims no personal credit for APOC's achievements, insisting they are the product of team work by the programme's committed staff at all levels, coupled with the unalloyed support of countries, donors and sponsors.
She underscored the high-level support of the WHO Regional Director for Africa, Dr. Luis Gomes Sambo, the unwavering commitment of donors and other stakeholders, including APOC's governing body, the Joint Action Forum (JAF), the Committee of Sponsoring Agencies (CSA), the Technical Consultative Committee (TCC), which provides technical and strategic guidance on the direction of the Programme, and Ministers, Ministries of Health workers and governments of participating countries. The Nigerian scientist equally acknowledges the contributions and support of former OCP and APOC directors, who share their expertise and experiences with her management team, towards the achievement of APOC's mandate. But she is not under any illusions about the daunting challenges ahead. "We have recorded many milestones, but we still have a lot of ground to cover,'' she affirmed, stressing that the ultimate goal is to empower communities to take charge of their own health. According to her, community-based initiatives, whether in health or other sectors, can only be sustained when communities are part of decision-making, planning and management. The CDTi strategy, the APOC trademark, is now being used to protect more than 92 million people from onchocerciasis infection, while 37 million people infected with the disease are being prevented from developing the relentless itching, skin disease or blindness associated with the clinical disease.
APOC has trained more than 38,000 health workers and over 472,000 Community-Directed Distributors (CDDs) of ivermectin in 16 African countries, who provide the human resources necessary for the implementation of the strategy. In 2007 alone, onchocerciasis-endemic communities with the support of NGDOs and donors treated 48.6 million people in Africa. But the task remains enormous in countries, and especially so in countries in conflict and even post-conflict nations, a number of which are under APOC's mandate, hence the passionate appeal by Amazigo for the cessation of conflict in Africa so that health care can be delivered to poor, remote and needy communities. The good news is that results of an ongoing scientific study in Mali and Senegal have already shown that it is possible to eliminate river blindness transmission from Africa using ivermectin treatment alone over an unbroken period of time.
The findings from the Onchocerciasis Elimination Study reinforce APOC's belief in Community-directed intervention (CDI) as a powerful tool for the strengthening of health systems through the empowerment of communities. Certainly, CDI is community-driven and APOC is in fact, leveraging on the burning desire among communities to help themselves to push and expand the boundary of self-help in health care delivery.
Apart from empowering communities to assume ownership and control of their health, the CDI approach has become a model and APOC is advocating the use of this approach for the delivery of multiple health interventions including Vitamin A supplementation, home management of malaria and distribution of treated bed nets. The case for the integration of the CDI strategy into health systems has indeed been strengthened by impressive results from a new multi-country research in Cameroon, Nigeria and Uganda.
The study, requested by APOC's governing body and coordinated by the WHO Geneva-based Special Programme for Research and Training in Tropical Diseases (TDR), has shown that when community members themselves lead the process of drug delivery and treatment better all round outcome is achieved. Doubtless, APOC's cost-effective disease control strategy has achieved impressive results. Communities are happy for their improved health and donors and sponsors are satisfied with handsome value for their money. "We have come a long way and we cannot afford to slacken," Amazigo affirmed. "APOC's success is an African victory; community-directed intervention is a strategy developed by Africans for Africans. It should be expanded for use by other control programmes to achieve a better outcome."
But like every other time-bound project, APOC has an exit date of 2015, so the Amazigo-led management is planning the programme's decentralisation and devolution, preparing countries and partners to assume complete ownership of the control activities. With Africa well on the way to defeating river blindness, and to ensure that the gains of over three decades are not jeopardised, the stakeholders must seize on the momentum built by APOC's community-directed intervention strategy to ensure the elimination of the disease as a public health problem in Africa, and towards the attainment of Health for All and the health Millennium Development Goals (MDGs) on the continent. For Amazigo, integrating APOC's activities with the health system is a golden opportunity to leave a lasting legacy for the benefit of poor remote communities. And if Africa is to attain the health MDGs by 2015, building partnership between communities and the health systems to strengthen the latter through community participation and ownership is inevitable.
With women proving a point or two in leadership in a male dominated world, especially in Africa, the Nigerian scientist has already carved a niche for herself as an icon in global health management, although she remains coy about being ranked among other great African female achievers, insisting that her best is yet to come.