The Global Elimination of Lymphatic Filariasis - The Story of Zanzibar

"Almost everyone in Zanzibar, nearly a million people, needed to be convinced that they had to swallow free but potent drugs. And they all had to do it on the same day, Saturday, 27 October 2001....And if it worked, then 27 October would be the beginning of the end for the stigmatizing and incurable parasitic disease known as lymphatic filariasis (LF) [the disfiguring condition also known as "elephantiasis"], the world's second leading cause of disability."

This report describes and assesses the first year of a lymphatic filariasis (LF) elimination programme implemented by the Global Alliance to Eliminate Lymphatic Filariasis, which is led by the World Health Organization (WHO), in Zanzibar, where - at the time the campaign was launched - approximately 15% of people carried the parasite, with infection rates well over 30% in some villages. Challenges in designing the mass drug administration (MDA) strategy included the presence of widespread misconceptions about LF (e.g., that the disease was caused by witchcraft or eating green coconuts) and, once the campaign was launched, the fact that rumours began circulating that the free tablets were a form of birth control or had unknown side-effects. MDA is built around dosing entire populations at risk with LF drugs once a year for five years. To be successful, it requires that a substantial proportion of a population participate for at least 5 years.

The opening sections of the paper explain how LF infection occurs, what effects it has on the body (the swelling of reproductive organs and lower limbs), and the psychological, economic, and social impact it has on those living with it: According to Kassim Ali, a community health nurse, "They have shame to walk among the people. Working is reduced. Wounds make [an] offensive smell. People tend to isolate themselves."

To help develop a social mobilisation plan, WHO sent 2 experts to Zanzibar in late June 2001 to work with the local authorities. One of the advisers had originated a marketing strategy for promoting health behaviours known as COMBI (Communication-For-Behavioural-Impact). At the heart of COMBI is an intimate understanding and appreciation of the perspective of those who will benefit from the programme. To better understand their "customers", the WHO social mobilisation advisers began what they called "walking around research". They travelled to villages and knocked on household doors and asked to chat. They learned that value of the drugs was perceived to be low since most people felt they were not at risk for LF or they could avoid the risk altogether by not eating green coconuts. COMBI also identifies the barriers and constraints that may prevent people from taking up the treatment. WHO advised and the Zanzibari authorities agreed that delivering the free drugs directly to the home would entail the lowest possible cost.

The campaign recruited and trained 3,000 Filaria Prevention Assistants (FPAs) to serve as something akin to door-to-door "personal sellers". To establish trust, they had to be seen as a neighbour, be of good character, be respected in their communities, and be committed to eliminating LF. They had to be knowledgeable about the drug and disease, and needed to be trained, primarily through role-playing exercises, in how to engage people inside the homes they visited. They were also provided with LF badges, tee shirts, and caps and supplied with tools they needed for their work, which earned them US$16 for a week's worth of work. The FPAs made 3 visits to each home. The third visit, on Filaria Day ("F-Day") involved delivering the drug.

To reinforce the messages delivered by the FPAs, a series of radio and television messages was distributed. Banners were also stretched across roads. Teachers distributed LF fact sheets to students, and asked them to read the material to their parents. Closer to F-Day, local political leaders, called Shehas, were asked to spread the LF messages at community meetings, and religious leaders (Imams) were asked to include a mention of the programme as part of their sermons in the mosques on Friday, the day before F-Day. Sound trucks announced that F-Day had arrived, and radio and television stations broadcast the news of Zanzibar's President swallowing the tablets himself. A "mopping up" day was arranged on the day following F-Day to reach those people who had somehow been missed.

The section of the report called "The best laid plans..." describes what happened after the WHO advisers left the island. Senior government officials had endorsed the plan, but dropped some of the proposed activities, in part due to the fact that they were worried that such an intense effort might itself create suspicion. Other challenges are described, such as bureaucracy and a mix-up that led to the drugs barely arriving in time. In the section titled "Decision to postpone or continue", the author of the report details the experience of the WHO advisers who returned to Zanzibar in early October 2001, when she learned that two-thirds of the COMBI plan had not been completed. Essentially, she found that there was a high awareness of the programme in the country and the FPAs had carried out the first visit. So, the decision of those involved in the programme was not to postpone but to rapidly unfreeze the funds, do what could get done, and continue with F-Day as planned.

In "The vital link", the author describes some of the challenges the FPAs faced in the days leading up to F-Day, characterising these people as often overworked and yet dedicated - using their own funds to buy school exercise books for the record-keeping, for instance. Then, the way F-Day itself unfolded is outlined in detail. The media covered the event, which included beating of drums and dances specially commissioned for the day. Throughout the day, radio and television broadcast the message: "Take your tablets. Support the campaign." Yet, problems arose. Some people were suspicious because the drugs were free. Some people had not been registered. And then, by late afternoon, one sheha after another reported that they had run out of drugs. Later that evening, district supervisors met to figure out where there was an oversupply of drugs and how to get those tablets to districts that had exhausted their supply. On mop-up day, media reports and personal accounts began reaching the reluctant population with word that national and village leaders had taken the drugs. An independent survey confirmed that, by the end of that day, 76% of the total population had taken the drugs.

Keys to success of the LF initiative in Zanzibar are described in the closing sections of the paper. Here is an excerpt: "Vital to the success of the programme was the strong and committed leadership of the government and civil service, the dedication of health workers, teachers, and young people, as well as the ownership of the programme by local communities. A strong foundation has been laid in Zanzibar which can be further enhanced by attracting and tapping into local resources, talent and expertise, and through creating meaningful partnerships with other stakeholders, private businesses, individuals and social groups."