An aim and a hope / [interview with] Ralph H. Henderson

An aim and a hope At the beginning of this year, WHO created a Tropical Diseases Control Division , which will work closely with the UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TOR) , set up in 1976 to promote research on tools to control the tropical diseases. Dr Ralph H. Henderson, for the past 13 years head of the Expanded Programme on Immunization, was appointed an Assistant Director-General of WHO with the responsibility, among other things, of overseeing TOR and the new control division. In an interview with World Health, he described how research and control of tropical diseases could be part of a greater effort to translate the ideal of primary health care into a worldwide reality. WH: How do you see the two tropical disease programmes - one for control, the other for research - working together? RH: Rather like team-mates in a relay race. For many diseases TOR, through its research promoting efforts, has a number of "batons" such as drugs, candidate vaccines and diagnostic kits, which they are ready to pass to the control people. And the new control division will provide a home for these products. But as in a relay race, passing the baton between research and control sometimes goes quickly, sometimes not so quickly. We are seeing the need for more applied research in cases where control pro- grammes experience difficulties in using the tools which research has provided. WH: For example? RH: Ivermectin, the new drug against river blindness, is a good example. TOR has been involved in getting the drug to the point where it can be safely and effectively used in the field to stop people going blind. Merck and Com- pany, the manufacturer, is even provid- ing the drug at no cost to countries with river blindness. So far · so good. But to deliver the drug to the people who need it costs about US $5 per person. Few developing countries can afford this, so as a result too few countries have been taking advantage of Merck's offer. It follows that there is still a lot of work to be done to determine how the drug can best be got to people and administered in a safe, effective and cheap way. Plann- ing, training and management are all involved. This is an area where both programmes - research and control - will have to work together to find a solution. WH: What kind of solution? RH: One solution might be to study 8 how the drug can be matched with other products so as to produce an overall health package. Such a pack- age might include vitamins to prevent malnutrition and blindness, vaccines against several diseases, oral rehyd- ration salts for children with diarrhoea, health education counselling, advice on birth spacing, promotion of breast feeding, and so on. Delivering a dozen or so of the most essential health items to whole communities might not cost very much more than delivering a single drug like ivermectin. Gotcha! Using himself as living bait, a catcher in the Onchocerciasis Control Programme in Burkina Faso captures the blackfly pest that spreads river blindness. WH: You're really talking about three levels of coordination or synergy: between research and control, between the different control products, and between these products and all the other elements of primary health care? RH: Yes. The new structure will mean that the researchers (those who develop the drugs, the vaccines and so on) will work more closely with the control people (those who have to use these drugs and vaccines). It will also mean more intensive work on control of specific diseases. A more integrated approach will ensure that the leprosy people are not just interested in leprosy, the schistosomiasis people in schistosomiasis and so on, but they are all looking for ways to apply technolo- gies and strategies in several areas, as part of an integrated programme to improve community health. And a third level is bringing the community into the picture, so that when a child with diarrhoea is brought to a health care facility, for example, the health worker doesn't just "turn on" the diarrhoea intervention. He looks at the overall health problems of the child, the child's family, and the community. WH: All these elements of the health package have been part of WHO's overall efforts for years now. Do you feel that the next decade has a better chance than previous decades of bringing these efforts to fruition? 1 RH: In the 1980s, we've been spinning ~ individual threads, corresponding to g. the different WHO programmes, such ~ as those dealing with diarrhoea! diseases, acute respiratory infections, immunization, essential drugs, tropical disease research, and so on. The 1990s will have to be the decade in which we weave these threads into a comprehensive primary health care fabric. And we do stand a better chance of succeeding now: while we've been spinning the threads, we've been learning how to deal with the relatively simple elements of each programme - training, management, monitoring and evaluation systems, and so forth. As we have built up each individual W ORLD HEALTH, June-July-August 1990 Researchers like these in central Africa are engaged in a life-and-death struggle against malaria. programme, we have been building a critical mass of managerial skills at the national level, able to deliver technolo- gies where they're needed. We're now seeing a real impact at the peripheral level. We have a mature immunization capability and a relatively mature diar- rhoea! disease control initiative, to WORLD HEALTH, June-July-August 1990 WHO/J. Mohr name but tvJo examples. And with the maturing of each programme, it becomes easier to add on other pro- grammes and gradually to weave all the threads together into the overall fabric. That's how I see our job for the next decade. We have to be good weavers! WH: Learning to be a good weaver sounds fine, but when countries are in a life-or-death struggle against a disease like malaria, a disease that seems to be thumbing its nose at our control efforts and . may not wait while we weave, what can we do to contain the problem? RH: Yes, malaria is a real problem, and one that is growing as the parasites learn to resist anti-malarial drugs and the mosquito vectors learn to resist insecticides. Until a universal tool such as a vaccine becomes available, we may have to put aside thoughts of controlling, let alone eradicating, malaria infection. We may have to step backwards for a while and see if we can't at least drastically reduce the number of deaths, mostly child deaths, from the disease. We should aim at providing children with anti-malarial drugs as soon as they become sick, so as to get them over their first infection and allow them to build up some degree of immunity to subsequent attacks by the parasite. We can also ask communities what they can do to reduce the problem, even if it means turning to less sophis- ticated solutions, like insecticide- impregnated bednets or curtains, like repellents or other means of avoiding mosquitos at peak biting times. On a global level, in response to concerns raised at the meeting of WHO's Executive Board in January, WHO is planning a ministerial confer- ence on malaria to be held within the next tvJo years, to try and sensitise political leaders to the problem. WH: You mentioned smallpox eradi- cation and the expanded immuni- zation programme, widely regarded as tvJo of WHO's success stories. You have been associated with both. What is the secret of running an effective health programme within a large international bureaucracy like WHO? RH: Ensuring the right match bet:vJeen simple tools and good managers. The secret of the immunization programme has been in having vaccines that are so simple, effective and inexpensive that they cut right through the constraints of a heavy bureaucracy, not only at WHO headquarters in Geneva but out in the regions and the individual countries. Management was a question of boiling down immunization schedules to a simplified scheme, easy to teach and easy to put into effect in local situations. Once in a while you see that match bet:vJeen a "do-able" technology and managers who can make sure its done, and then the sky's the limit. With the new tools that are emerging from tropical disease research and the new management structures that are being set up to use the tools, we may well be setting the scene for some more success stories. That's the aim and that's the hope. • 9