Finishing off lymphatic filariasis: How Maldives eliminated a once-prominent scourge

Ministry of Health, Maldives

Lymphatic filariasis (LF) can have a powerful effect on the human psyche. For those who suffer LF, anguish and shame is an experience as common as deprivation and disability. And for those who live where LF is found, fear and dread too often win-out over compassion and care. Discrimination can result.

Mohamed Ismail Fulhu, once part of an LF blood-sampling team in Maldives’ southern atolls, remembers when in the 1960s he first encountered the psychological impact LF can have. While doing his rounds, a villager asked him: “How can you not worry for your own health when you go to do the blood sampling? I will not even walk in their footsteps because otherwise I too will get sick like them.”

More than 50 years later, Maldives’ experience of LF has changed dramatically: In 2016 the country was certified to have eliminated the disease as a public health problem. Across the country, vulnerable communities need no longer suffer or fear the swollen extremities, disability and mental anguish caused by the disease, which is more commonly known as elephantiasis. That Maldives was the first in the South-East Asia Region to make this happen demonstrates how far it has come, both in addressing the disease’s biosocial components, as well as enhancing technical capacity to defeat the parasites that cause it.

Dr Arvind Mathur, WHO Representative to Maldives, explains how the milestone was achieved. “In the late 1960s more than 6% of Maldives’ population carried filarial parasites in their blood. Though efforts were made to tackle the problem, progress was slow. In recent years, however, political commitment has been strong, allowing health authorities to sustain mass drug administration campaigns that provide at-risk communities several rounds of preventive drugs annually. This occurred alongside mosquito control efforts, as well as a greater emphasis on case identification and treatment,” he says.

According to Dr Mathur, robust and sensitive surveillance proved crucial to overcoming last-mile challenges. "Good surveillance was a game-changer. It gave health authorities the ability to better target interventions and overcome hurdles in the campaign’s final stages. Importantly, the infrastructure now in place will help maintain elimination status while vanquishing other neglected tropical diseases,” he says. “With continued commitment, Maldives will make further path-breaking advances.”

Maldives’ success reflects a Region-wide focus on ending neglected tropical diseases for good. Since 2014, doing so has been one of the Region’s Flagship Priority Areas. Clear targets have been identified: By 2020, LF, visceral leishmaniasis, leprosy and schistosomiasis should be eliminated. The Region should be free of yaws.

“Maldives’ success is testament to what can be achieved when full political commitment is mobilized. That is now happening across the Region,” says Dr Poonam Khetrapal Singh, Regional Director of WHO South-East Asia. “India, for example, is now yaws-free. Following Maldives’ triumph, Sri Lanka has eliminated LF. Nepal is on the cusp of eliminating trachoma, and has maintained the elimination target for visceral leishamiasis for more than three years. 98% of sub-districts in Bangladesh and 85% of blocks in India have achieved the same,” she says.

According to Dr Khetrapal Singh, the right policy interventions are being made. It’s just a matter of fortifying resolve.

“Across the Region, mass drug administration has been be scaled up; innovative, targeted solutions are being identified and deployed; and efforts to achieve universal health coverage are being enhanced. Strengthening these activities will see us reach our NTD goals, as well as the Sustainable Development Goal of ensuring health and wellbeing for all,” she emphasizes.

For Maldives’ health authorities, the psychological power of success is likely to hasten momentum in the battle against neglected tropical diseases specifically, and in forging other public health gains broadly. As Abdulla Nazim Ibrahim, Maldives’ Health Minister explains, "By eliminating lymphatic filariasis we have gifted our people a future free from a debilitating and deeply stigmatizing disease. It is testimony to what can be achieved when science and society fully embrace each other."