Reaching the last mile

According to the WHO definition of the term, “neglected tropical diseases” refers to a group of 17 communicable diseases that occur in 149 tropical and subtropical countries and  “mainly affect populations living in poverty, without adequate sanitation and in close contact with infectious vectors and domestic animals and livestock”. These include well-known diseases such as dengue, sleeping sickness and leprosy – but also less familiar ones like river blindness (onchocerciasis) and lymphatic filariasis. These latter ones are at the focus of the WHO initiative ESPEN – the Expanded Special Project for the Elimination of Neglected Tropical Diseases.

“We want to reach 145 million people in 26 countries by 2016,” said Magda Robalo, Director of the Communicable Diseases Cluster (CDS) at the WHO’s Regional Office for Africa, explaining the ambitious goal of the initiative, which is to run for five years, at at an event in March held by the German network against neglected tropical diseases in Berlin. Instead of single disease initiatives such as the African Programme for the Control of Onchocerciasis (APOC), which expired in December 2015, an integrated, multiple disease approach is to be applied in future that “puts the countries on the driver seat” and gives them space to define their own priorities.

The African Region bears about 40 per cent of the global burden of NTDs. All the 47 countries of the region are endemic for at least two NTDs, and ESPEN requires an annual budget of ten million US dollars to support ist operations. So far, however, the WHO has only two million US dollars at ist disposal for this purpose.

Magda Robalo demonstrated how well financial means had been invested in combating NTDs with the example of Guinea worm disease. In 1986, 3.5 million cases had been reported, but by 2015, numbers had dropped to 22 cases, and the disease is now close to eradication. The trend in the number of people surviving HIV/Aids also clearly reflected how much success could be scored if political will and public attention were there, and, above all, enough money was provided and the right drugs were developed.

However, all these factors are usually still posing problems in combating NTDs – despite a number of good drugs being available, as Professor Achim Hörauf, Director of the Institute of Medical Microbiology, Immunology and Parasitology at Bonn University, pointed out. At the meeting
in Berlin, Hörauf referred to the agent Ivermectin, which is used to tackle river blindness and lymphatic filariasis. Furthermore, many drugs are now being provided by pharmaceutical
companies free of charge.

However, the way the parasites live, and hence the duration and type of therapy, often thwart the efforts of the medical scientists. For example, Ivermectin only kills off the larvae of the worms (so-called microfilaria) that cause river blindness. But as long as the adult female worms are living under people’s skin, and they do so for up to 17 years, the programmes to combat them have to be consistently continued. “Each year, therapy has to reach people even in the remotest areas”, Hörauf noted.

This is one of the greatest challenges in combating neglected tropical diseases, which “often start where the roads end,” as Professor Martin Kollmann, Senior Advisor for NTDs at Christoffel Blindenmission (CBM), put it. Efforts to permanently master the diseases will not meet with success if the health systems themselves are not strengthened. Here, capacity building in the countries affected, involving the rural communities and especially supporting the peripheral health services, would have to be a priority in order to ultimately achieve the goal of universal health coverage. Magda Robalo rounded off the event with an optimistic forecast: “If Coca Cola can manage to get to even the remotest village, why shouldn’t we be able to do so with healthcare?”

Silvia Richer, editor, Rural 21