Containing neglected tropical diseases: extending efforts to reduce global impact .

Infectious disease

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Dr Robert Bergquist reflects on the World Health Organization’s Roadmap for the control of a number of neglected tropical diseases (NTDs), the inauguration of ‘World NTD Day’ and the prospects of elimination of disease through health-related poverty alleviation.

The 30th January 2020 is a decisive day in the fight against neglected tropical diseases (NTDs). Designated ‘World NTD Day’, it marks exactly eight years since the World Health Organization (WHO) released its Roadmap outlining targets for prevention, control, and elimination of a set of infectious diseases locking a large part of the world into a vicious circle of poverty and poor health. The original group of 17 target NTDs presented in the proceedings of the highly influential WHO meeting on ‘Accelerating work to overcome the global impact of neglected tropical diseases‘, was enlarged in 2016 to 20 diseases, now including infections due to helminths, protozoa, fungi, bacteria and viruses.

Inspired by the WHO Roadmap, a meeting spearheaded by the Director-General of WHO at the time, Margaret Chan, and Bill Gates of the Bill & Melinda Gates Foundation (BMGF) was held at the Royal College of Physicians in London, UK on the very day the Roadmap left the presses in 2012. This meeting included stakeholders representing international organizations, major pharmaceutical companies, donor organizations as well as governments in both industrial and endemic countries and it resulted in the joint launch of the ‘London Declaration on Neglected Tropical Diseases’ where all participants unanimously agreed to eliminate or control 10 NTDs in the world’s low- and middle-income countries by the early 2020s. Up to $800 million was allocated over the next ten years for research and development of diseases affecting 1.5 billion people. The pharmaceutical companies pledged provision of free drugs, while large foundations such as the BMGF, bilateral donors such as the British Department for International Development (DFID) and the United States Agency for International Development (USAID) would support the distribution of the medical supplies needed, assisted by WHO and the World Bank.

The London declaration has strengthened considerably over the last eight years and is now endorsed by more than 70 non-governmental organizations (NGOs), academic institutes, and charitable associations, in addition to the founding members, whereas many national governments have announced local implementation of the programme. Not only to honour the show of support received so far through the London Declaration, but above all to inspire and rally partners each and every year behind the fight to defeat the NTDs, the World Health Assembly declared at their annual meeting in 2019 the date 30 January as ‘World NTDs Day’.

All of this is good, indeed excellent and above expectations, but to achieve the goals of the London Declaration and the Sustainable Development Goals (SDGs) of the United Nations’ Agenda 2030, civil society advocates, community leaders, global health experts and policymakers must work together across the NTD landscape whose traits, depending on geographical focus, may vary considerably. In a scoping review in this issue of Infectious Diseases of Poverty (IDOP) Engels and Zhou discuss the fight against the NTDs, demanding an updated assessment of the NTD targets, renewal of the London Declaration commitment and the launch of a new 2021–2030 roadmap. Although much has stayed the same since the start of the London Declaration in 2012, much has also changed. For example, the major health indicators of China now surpass those of the whole group of countries with economies having reached the level of middle- and high-incomes. The Editorial by Wang and Zhou in the same IDOP issue discusses the achievements of the latest Chinese five-year programme on poverty-related disease priorities, noting that more than 70 million people have been lifted out of poverty, an astonishing feat with regard to the short time the programme has been active. The challenge to win the war against the NTDs remains, however, enormous and winning requires that no country or organization rests on its laurels. Moving forward is now more important than ever and in doing so poverty alleviation is the next step. The following set of statements will be helpful in building a platform leading in that direction:

1. Health-related poverty alleviation
• In their scoping review, Engels and Zhou stress the need to integrate current NTD interventions into national health systems. However, this would only work as part of Universal Health Coverage, defined as access to health services for all, when poverty alleviation is recognized as a local priority. The national health systems need therefore to be responsive, applying sound technical and managerial knowledge at all levels, something that often must be developed from scratch.

• To achieve the goals set, all countries endemic for one or more NTDs need to develop a social-economic plan for the new decade. The data presented in the editorial by Wang and Zhou indicates that poverty is the major cause of the NTDs, in particular in low-income tropical countries, where a large proportion of the population live in subsistence societies under the poverty line. Thus, without health-related poverty alleviation, NTD elimination at the national level will not occur and the SDGs are even less likely to be achieved. Moreover, in steadily growing economies, impressive disease reductions can take place. By moving 70 million people above the poverty line since 2015, China has achieved the first target of its health-related poverty alleviation programme. There is more to come and also other countries can follow but many will need outside financial support and it important that this support is injected in a way that invigorates ailing economies and reduces poverty.

2. Defeating the vicious cycle of poverty and disease
• Seeing poverty as the root cause of ill health redirects approaches from isolated, direct health interventions to a dual scheme emphasizing also the role of poverty that adds financial burdens to stricken households. Changing gears, the Chinese Government have improved the medical insurance system, provided free or reduced cost for treatment and health services, particularly supporting maternal and child health and strengthening the general social support system. All registered poor people now enjoy a three-tiered financial protection, namely basic health insurance, major disease insurance and medical financial assistance schemes. This approach not only assists control of infectious diseases, such as the NTDs, but also hypertension, diabetes, tuberculosis, mental disorders and other common medical disorders.

• The Chinese Government have invested in standardized construction of county and township hospitals and village clinics, promoting tiered and integrated health services delivery, supported hospital-to-hospital assistance between urban and rural areas, and encouraged medical college graduates to work in rural and remote areas.

• Since times immemorial, endemic diseases, the NTDs in particular, have played a critical role in holding back development. Activities to control these diseases are still run as separate programmes, but have recently been oriented more closely to new poverty alleviation programmes. For example, filariasis has been eliminated in China with malaria, echinococcosis and schistosomiasis soon to follow. The schistosomiasis elimination programme serves as a good example which has benefitted from high-priority special support for 70 years thanks to Chairman Mao’s early understanding of its grave impact. A combination of continued political will and a sustained, multidisciplinary approach, including strong emphasis on equity and poverty reduction in areas where it is most needed, have helped control the disease as well as boosted the local economy. Meanwhile, activities related to industrial, agricultural and water resources aimed at reducing disease transmission have reduced the number of infected cases, and the number of patients was less than 1000 in 2018.

3. Lessons learnt
• It is necessary to understand that the NTD impact is not only due to biological factors, such as infection and transmission, but that the disease is also affected by social-economic issues and therefore requires the application of one-health and ecohealth strategies as much as drugs when designing control programmes.

• Understanding the spectrum and nature of poverty-related disease, as well as concern for continuously updating strategies and interventions at all levels, is of course highly important. However, just as important are early-warning and surveillance-response systems. By combining disease prevention with treatment along the approaches of the health-related poverty alleviation programme, both the capacity of health services delivery and financial protection can be improved.

• Poverty alleviation must be accepted as a health-related prerequisite. The national health systems need therefore to be responsive, applying sound technical and managerial knowledge at all levels, something that often must be developed from scratch.

Concluding remarks
Before the chemotherapeutic/antibiotic era, specific therapy could not be offered. Now that we have access to this, drug resistance is a risk but the treatment context has been broadened to include strategies relying on one health, ecohealth, social-economic factors and more. Health-related poverty alleviation is a new approach with great attraction, but it should be pointed out that just 20 years ago, no endemic country had the economic growth allowing its application, neither did it appear useful to alleviate poverty before treating the infections thriving in its wake. However, the successful experience of China in eliminating some NTDs by combining disease prevention with treatment along the approaches of the health-related poverty alleviation programme, has shown that it can be done.