Tiny Togo Conquered Elephantiasis
WHY YOU SHOULD CARE
Ahead of the rest of sub-Saharan Africa and Asia, this tiny West African nation defeated a debilitating disease.
By Charu Sudan Kasturi
This OZY original series takes you to the doorstep of Developing World Lessons: stories of pathbreaking successes in education and health, technology and environmental protection, from Africa, South America and Asia, that are reshaping those societies and that the West too can learn from.
For years after the mosquito bite, everything seems fine. But the infection quietly spreads. The legs start swelling. The arms and genitals follow suit. The bloated body has joined a highly undesirable physical disease club, one of the world’s largest, with an estimated 120 million unwilling members across more than 70 countries. Until last year, 37 of those countries were in Africa. Then an unlikely nation escaped.
Last year, Togo became the first country in sub-Saharan Africa to eliminate elephantiasis — ahead of continental giants Nigeria and South Africa.
Among Africa’s poorest countries, Togo is surrounded by better-off neighbors that for decades have struggled to defeat lymphatic filariasis, a tropical disease commonly known as elephantiasis (the bacterial infection causes the skin of the swollen areas to resemble that of an elephant’s heavily wrinkled hide). Rising global powers India, Brazil and Indonesia also continue to wage war on an affliction that disables or disfigures 1 in 3 victims. Malaria is the only vector-borne disease that infects more people in the world.
Togo’s achievement, formally endorsed by the World Health Organization (WHO), is the culmination of almost two decades of smart interventions, say experts. The West African nation was among the first to take the WHO up on its challenge in the late 1990s to eliminate the disease, says Rachel Bronzan, a medical epidemiologist at global health care agency Health and Development International.
In 2000, after discovering elephantiasis was endemic to eight of Togo’s 40 districts, health experts launched a nine-year program of mass drug administration. In 2006, a network of 47 laboratories — at least one in each district — began collecting blood samples for Wuchereria bancrofti microfilaria, the bacteria behind the disease, even from districts where elephantiasis was not endemic. At the time, no other country had set up this type of nationwide surveillance system.
[It] demonstrates Togo’s commitment to this kind of work. There’s a lot other countries can learn from it.
Rachel Bronzan, medical epidemiologist
Sheer rigor hasn’t been the only driver of Togo’s success, though. One challenge: holes in the seemingly robust screening system. Many Togo families don’t record precise birth dates, so determining who could receive drugs was difficult (the WHO advises avoiding medication for children under the age of 5). But Togo has found innovative, out-of-the-box solutions to each of these challenges. “It’s a huge success and demonstrates Togo’s commitment to this kind of work,” says Bronzan. “There’s a lot other countries can learn from it.”
To be sure, Togo’s size gives it an advantage over larger nations. Covering a population of 8 million is easier than a population of 200 million (Brazil) or 1.3 billion (India). But surrounding nations — such as Burkina Faso, Benin and Ghana — have similarly small populations and higher per capita incomes, yet lymphatic filariasis remains endemic. And Togo’s dedication to defeating the disease is something even giants like India and Brazil have failed to match, say experts.
While identifying districts most affected by the disease, Togo’s health workers discovered that most such areas were already being administered treatment for onchocerciasis, widely known as river blindness. Togo adapted the existing program to add doses of albendazole, which treats elephantiasis, for all citizens covered.
Togo has also stayed nimble in tweaking its strategy when needed. After all, identifying vulnerable communities and administering drugs is all well and fine, but what about those already suffering from grotesquely swollen bodies? In 2007, Togo trained one staff member in each of the country’s 570 health facilities on educating and caring for patients with the disease. “The program sought to ensure sustainability beyond external funding by being low in cost,” notes a 2013 report written by Yao Sodahlon and an international team of scientists and published in the journal PLOS Neglected Tropical Diseases.
More evidence of Togo’s ongoing commitment? When the country discovered in 2009 that a few small pockets of its population were still uncovered by the 47 screening laboratories, it set up 20 more facilities, specifically for those neglected communities.
To address the challenge posed by the absence of age records for most children, health activists used sticks to measure the heights of children and used that metric to approximate age. And though it is now Africa’s leader in tackling the disease, Togo has been keen to collaborate with others. It joined the multicountry West African LF Morbidity Project, under which local surgeons were trained in WHO-recommended procedures for patients. In 2007 and 2008, surgeons conducted 215 such operations in Togo.
The country’s reliance on local and regional solutions to many of its challenges in this battle reduced its dependence on international aid, though support from global agencies, especially for a reliable supply of drugs, played an important role, say experts. “Support from international agencies has been important too, both in terms of money and technical support,” says Bronzan. “But the success lies with Togo.”
Risks linger, especially because the disease remains endemic to Togo’s neighbors. In 2015, authorities identified a migrant from Ivory Coast who was carrying the infection. “Because this is transmitted by mosquitoes, the risk of it coming in remains,” says Bronzan.
But its strong surveillance system gives Togo an edge in outflanking such risks. When it comes to battling one of the world’s most debilitating diseases, staying one step ahead is now second nature to Togo.
- Charu Sudan Kasturi, OZY Author Contact Charu Sudan Kasturi