The London conference on neglected tropical diseases (NTDs) held in January was a seminal moment in the global fight against a group of diseases which are often overshadowed in the global health agenda by HIV, malaria and TB.
NTDs – a medically diverse group of 17 tropical diseases such as soil-transmitted helminths (roundworm, hookworm and whipworm), blinding trachoma, schistosomiasis (bilharzia), lymphatic filariasis (elephantiasis) and onchocerciasis (river blindness) – typically affect the poorest of the poor. They affect one in six people globally; they rarely kill but disable and weaken, putting individuals at risk of other conditions and costing billions in healthcare and lost productivity.
Preventive chemotherapy, in the form of mass drug administration (MDA), has proved tremendously effective and economical (most drugs are donated): it costs just $0.5 per person per year to treat the seven most common NTDs.
At a follow-up meeting in Washington DC earlier this month, stakeholders discussed progress, partnerships and responsibilities.
Simon Bush, director of NTDs at Sightsavers, an international charity working to eliminate avoidable blindness, said there was much more to do. Top of his list was mapping, without which it is impossible to know the full extent of a disease's footprint and the resources required to eliminate it. "We must get it completed once and for all," he says. Sightsavers is currently leading a consortium funded by the UK government to complete the mapping of blinding trachoma by 2015. Many other diseases such as lymphatic filariasis and schistosomiasis need similar efforts.
Bush is also concerned about what happens at the other end of the process. "Where and when do we stop treatment? We need guidelines on elimination certification, otherwise all we do is keep popping tablets," he says.
The synergies between NTDs and Wash (water, sanitation and hygiene) have long been documented: a 1911 report from the Rockefeller Sanitation Commission on the eradication of hookworm in the US concluded that "cure alone is almost useless … because the patient can go out and immediately pick up more hookworm disease". The same remains true today and is widely acknowledged. "We know that not working in an integrated way undermines the effectiveness of both sectors," says Yael Velleman, senior policy analyst at WaterAid. The biggest challenge the NTD sector faces however, is to broaden its field of action. Bush says that amid the drive to extend MDA coverage, other measures have been overlooked. On the prevention side in particular, the NTD community must work more closely with the Wash sector.
Wash is an integral part of the World Health Organisation-approved Safe strategy to eradicate blinding trachoma. The first two letters stand for surgery and antibiotics, the 'health' part, while f and e stand for facial cleanliness and environmental change, two resolutely Wash tasks.
The issue, therefore, is not one of why, but how. There are programming challenges to overcome on both sides: NTDs used to be the realm of vertical programming and adjusting to a more horizontal, integrated approach takes time. As for WASH, outcome in the sector tends to be measured in terms of access and coverage, not health indicators. Velleman also points out that funding often lacks the flexibility to tackle issues not perceived as core.
However, there are many examples of best practice to follow. In Ghana and Ethiopia for instance, WaterAid decided to shift its target areas to those with high trachoma prevalence. The organisation is also part of the consortium that will carry out the trachoma mapping; the plan is to map Wash coverage at the same time and use the data for Safe planning.
Save The Children's school health and nutrition programme in Bangladesh and Nepal successfully managed to reduce worms in children and improve Wash practices thanks to health promotion activities in schools. And in Latin America, the Inter-American Development Bank now makes provisions for NTD funding in its Wash projects.
Neeraj Mistry, managing director of the Global Network for Neglected Tropical Diseases, says that the NTD community should also look further afield. Private companies operating in countries with high NTD prevalence have a stake in getting involved (it affects their employees, communities and potential customers), as do donors who have invested in nutrition, education or malaria/HIV, which could be undermined by NTDs.
There has also been much talk about NTD interventions strengthening local health systems, but beyond the use of community distributors, who form the backbone of mass drug administrations, there is no consensus on how to go about it.
Yet it seems NTDs are now firmly on the global health agenda. END7, the social media campaign launched by the Global Network for Neglected Tropical Diseases, has picked up pace – and celebrities. "The reason we launched the campaign was to generate a popular movement on the topic," says Mistry. "The NTD community was occupied by very technical medical staff whereas HIV and malaria had Bono and Elton John: that took them to a very public sphere and kept them on the development agenda, with strong donor support."
There are now plans to discuss a resolution on NTDs at the next WHO executive board meeting in January and the World Health Assembly in May. Bush says that a UN resolution would focus on member states, who would be obliged to report on their progress. "I'm not sure the people who came up with the term NTDs ever dreamt there would be such a high-level discussion at the UN. It just shows the momentum that the NTD movement has gathered."