Hollman Miller

In the mid-1970s, a 3-year-old Bangladeshi girl named Rahima became the last-known person with severe smallpox, a disease finally eradicated in 1980 after a targeted global campaign.

If Dr. Hollman Miller and his team have their way, there may someday be a person in the vast Colombian Amazon basin who is the “last-known” to suffer from one of the infectious diseases endemic there. And it will be because of integrated health programs.

Miller has worked for more than 25 years to reduce neglected tropical diseases (NTDs) among the indigenous communities in the Vaupés department of the Amazon rainforest in southeastern Colombia. Vaupés borders Brazil and is the least populated department in Colombia with just 41,000 people.

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The region’s lush rainforest is stunning but it creates unique public health challenges: 1) Vaupés sprawls across 54,000 square kilometers, much of it dense forest where the only way to access people is via small airplanes, boats or roads that are sometimes precarious, 2) it is home to more than 25 ethnic groups of varying languages and customs living in 250 distinct communities around nine major rivers, most of which are not interconnected, and 3) it is endemic to diseases such as blinding trachoma, soil-transmitted helminths (intestinal worms), scabies, head lice, leishmaniasis, malaria, Chagas disease, and tungiasis (skin disease) spread by fly bites.

In this unique setting, Miller is Coordinator of Vector-Borne, Zoonoses, and Neglected Diseases in the Vaupés Secretary of Health. His leadership and commitment to fighting these diseases was recognized with an award from the Reaching the Last Mile Fund, which lauded his pioneering work to develop a mapping, control and elimination program and his efforts to interrupt the disease transmission cycle and increase access to medicine and treatment.

“Indigenous communities bear a massive morbidity and mortality burden from these many diseases and Dr. Miller has been an advocate for these populations for decades,” said the award committee.

His long-time history in the area has convinced Miller of the importance of integrating public health activities to tackle multiple diseases simultaneously, particularly given the extreme measures needed to reach the affected communities. In some cases, he said, they have to fly in two planes – one for the health staff and one to carry the supplies, gasoline and equipment necessary to travel through the rivers. Providing services can involve up to 20 days of travel.

“Integrated campaigns are important because they help reduce costs in these environments that are so difficult to operate in and so costly to access,” he said. “They allow for carrying out different actions not only for one disease but also for other diseases that are prevalent and have common causes. It is the most adequate way to reach more people for a longer period with much more effective actions.”

In 2021, in order to reach the community of La Sabana, home to 13 families of the Cubeo people, a group of health workers, with leadership from the Universidad de los Andes, rode eight hours by motorboat on the Cubiyú river. They carried jerry cans of water, backpacks, and royal blue life vests reading Secretaria de Salud Departmental.

Video from their journey shows dense green foliage along the river, which spanned wide at some points and narrowed at others, the river’s glassy brown water then turning frothy as it churned over rocks near the banks of La Sabana. In the village, parents and children gathered in a large A-frame structure with a palm-leaf thatched roof, sitting on wooden benches to discuss their health issues.

A health promoter on the trip described the impact of diseases by saying “they create a nuisance, a blood deficiency, and a hemodynamic instability in certain moments, in which case it is important that kids are safe.”

Miller went further, noting that the diseases have additional implications for well-being and development.

“We don’t gain anything by having teachers when the kids, due to intestinal parasites, head lice, scratching or scabies, can’t sleep and can’t concentrate in their studies,” he said.

“There is no gain for the government in offering services when the users of those services are not in the best condition to take advantage of them.”

Miller’s conviction about serving the people of Vaupés is clear when he describes the threat of the diseases in the Amazon basin.

“It’s important that these communities reach these health indicators so they can stop being at a disadvantage to the rest of the country. If you’re going into a community that is already hard to penetrate, it’s important to take the largest number of actions combined to improve the livelihood of that community,” he said.

This approach of integrating health campaigns to target multiple diseases is central to the work that Miller’s team is doing with The Task Force’s Health Campaign Effectiveness (HCE) Coalition. The Coalition supports research on how countries can enable integrated health campaigns, as well as identify barriers to and outcomes of such campaigns; fosters testing and replication of evidence-based practices; and develops guidelines for better collaboration between health campaigns so that country health systems can meet their objectives.

In partnership with the Universidad de los Andes and local and indigenous authorities, and with funding from the HCE Coalition, the Vaupés health department developed a plan for the elimination of trachoma and reduction of soil-transmitted helminths (intestinal worms) and ectoparasitosis (skin parasites like scabies and tungiasis).

Their approach includes mass antibiotic and deworming drug treatment campaigns, environmental interventions, animal health, and behavior change strategies to promote hygiene. This supports a region-wide initiative to eradicate and eliminate 30 diseases in Latin America and the Caribbean by 2030, led by the Pan American Health Organization.

For the Amazon basin communities the issue of access to health services is an ongoing challenge. The COVID-19 pandemic, of course, complicated things further.

“The pandemic impacted us in a very strong way in the sense that any possibility of reaching those communities to continue the work that had been carried out was reduced, especially for these neglected diseases,” said Miller. “We generated a prioritization for surveillance of events, such as rabies and dengue outbreaks, but there were many regular actions that were left without being able to develop in indigenous communities.”

At the same time, health officials discovered that COVID-19 had spread into the communities via river routes from neighboring Brazil, since the Amazon basin spreads across eight countries.

Despite the many challenges, Miller is clear on both his goal and the enjoyment he gets from his work.

“My job has been tied to this community since forever, my connection with this community started since I started this job. We’ve been deployed to every part of the 54,000 kilometers of rainforest,” he said. “It is a clear decision to support the communities in whatever way we can to reduce suffering and death and to prolong life.”

The Last Mile Fund award committee captured Miller’s dedication with another quote.

“I have seen the damage and suffering that neglected tropical diseases have caused to children and elderly people in those communities. This is the reason why working with and for these isolated communities is my life project, and I hope to do this until the end of my days.”

Someday in the future, the story may be told of the last little girl in La Sabana to have an NTD. And it will be people like Hollman Miller and his team who make it possible.

Watch the video below on Microplanning Campaigns in Colombia.

Photos courtesy of Hollman Miller and Shutterstock.