Factores eco-sociales de la zona

A culmination of events occurred on the 30th of January 2012 at 'The London Declaration'. On this day, a collection of international politicians, pharmaceutical CEOs and heads of global health organizations, including Bill Gates and the Director of the World Health Organization Margaret Chan, descended on London. What was striking about this gathering of leaders was the presence of big pharma, led by Bill Gates as a domineering force in public health through the philanthropic Bill & Melinda Gates Foundation. Gates was already completely changing the landscape of public health through his $39.6 billion endowment to the foundation as of 31 December 2015 from 2006 with priorities set in the areas of health, development and education.⁶⁸ By the account of Molyneux, Gates was central, but there were others who were instrumental in making the London Declaration happen: "It was DIFID [UK Government Department for International Development] and Gates... supported by pharma partners particularly by Andrew Whitty from GSK [GlaxoSmithKline]⁶⁹ with Lorenzo Savioli driving the agenda from the WHO side” (First interview with author, Molyneux, 2016).

This was a meeting for setting goals and forming a collective vision to tackle NTDs, echoing the Millennium Development Goals (MDGs) 12 years before. The MDGs were eight targets set to be reached by 2015, addressing the needs of the world’s poorest people and agreed by all countries at UN. The collective prioritization of NTDs and goal-setting at the London Declaration was reminiscent of the MDGs but this time directed specifically at NTDs. Many involved in NTDs highlighted the omission by the MDGs and how donor attention and funding was directed towards the 'big three'. As Molyneux describes, policy-makers and politicians,

"...overfocus on unachievable objectives and targets around the ‘big three’ diseases, which if the planet was viewed by aliens would be seen as the only diseases that existed on the planet"

(2008, p. 509).

68Gates Foundation, http://www.gatesfoundation.org/What-We-Do/Global-Health/Neglected-Tropical-Diseases, Accessed 2/4/14.

69 A British pharma company.

At the London Declaration, only 10 of the 17 WHO diseases were addressed, as the signatories decided that these were the ones that could be controlled or eliminated by the end of the decade: the diseases ripe for 'immediate targeted assistance'. This scope was in line with the early papers about integrating successful vertical programmes and explains the pharma company involvement. What the London Declaration was really about was the continuation of existing drug donation and research programs with some encouragement of further R&D. The commitments summarized, were as follows:

• Sustain, expand and extend programs, drug supply and access

• Advance R&D, collaboration/coordination

• Funding for implementation and technical support to evaluate and monitor the interventions

Table 7 Summary of London Declaration commitments

Through a public announcement of commitments to NTDs the intention was to address this shortfall and to coordinate action by 2020. NTDs were described as such:

"These diseases, many of which have afflicted humanity for millennia, affect more than 1.4 billion people. They sicken, disable, and disfigure, keeping people in cycles of poverty and costing developing economies billions of dollars every year. Until recently, NTDs saw little attention from all but a small handful of dedicated supporters. But as their impact grew clearer, more were urged into action" (Uniting to Combat NTDs, 2014, p. 4).

This is a typical description of NTDs. These are diseases of and causing poverty that have been around a long time (some for millennia), disabling and disfiguring more than killing, still affecting many with an impact on their economies. The final point is the one that must be emphasized the most. It is an acknowledgement that NTDs have been a neglected problem but the situation is improving. There are a number of diseases that can be included in this group, although it is striking there is no global consensus of what these diseases are or any standardized definition, with different organizations defining these diseases differently.

Other organizations' disease lists also tend to have lower more manageable numbers than the 17 making up the WHO list, with one exception. The open-access journal PLOS Neglected Tropical Diseases’ promotes a list of 38, and the journal is open to suggestions for other diseases to be included with appropriate rationale. The PLOS journal was established in 2007 through a $1.1 million grant from the Gates Foundation and with Peter Hotez as the founding Editor-and-Chief (The Official PLOS Blog, http://blogs.plos.org/plos/2006/09/announcing-plos-neglected-tropical-diseases/, Accessed 1/5/16). It has science, policy and advocacy mission according to Hotez to: "...be both catalytic and transformative in promoting science, policy, and

advocacy for these diseases of the poor" (ibid.). The main focus is on poverty and the chronic aspect of these diseases described as: "poverty-promoting chronic infectious diseases" with an impact on "child health and development, pregnancy, and worker productivity, as well as their stigmatizing features" (PLOS Neglected Tropical Diseases, http://journals.plos.org/plosntds/s/journal-information, Accessed 4/16/5). The diseases in addition to the WHO 17 are many viral and bacterial diseases, and five (loiasis, Japanese encephalitis, Jungle yellow fever, cholera and pinta) are those originally listed by Patrick Manson. A British physician he was founding director of the London School of Hygiene and Tropical Medicine (LSHTM) and largely behind creating the specialism of tropical medicine. His book 'Manson's Tropical Diseases: A Manual of the Diseases of Warm Climates' (1898),⁷⁰ was definitive in the construction of the tropical disease grouping and lists a catalogue of 65 infections or diseases from the minor 'prickly heat' to the more serious malaria and yellow fever.⁷¹ This list will be discussed in greater detail in the next chapter.

The reason for those diseases not to be included in the WHO list appears to be because of the lower incidence rate, or lower level of severity, or both. Japanese encephalitis and jungle yellow fever cause periodic outbreaks, which is why the WHO groups them under information for emergencies. Other diseases listed are what the WHO call 'Water-based diseases' and diseases that come under 'International travel and health'. I have ordered these different groups into the figure below.

70Manson developed the 'mosquito theory' of infectious disease transmission, founded the LSHTM in 1899, and was the first president of the Royal Society. In fact these diseases reflect partly the older tradition of 'diseases of warm climates' included in the title. He places more of an emphasis on the European coping with a tropical environment than what came to be the colonial project of tropical medicine, a more all-encompassing programme of health and sanitation. However, while reflecting on the older tradition, Manson wanted to break with the medico-geographical distinction and bring in modern scientific grounds for differences in disease in temperate and tropical climates (see Edmond, 2006)

71The sub-categories Manson outlined are: fevers, general diseases of undetermined nature, abdominal diseases, infective granulomatous diseases, animal parasites and associated diseases, intestinal parasites, skin diseases, and local diseases of uncertain nature. One undetermined disease was the yet to be discovered cause of sleeping sickness (human African trypanosomiasis) transmitted by the tsetse fly.

Enteric pathogens

Figure 5 PLOS NTDs in addition to the WHO 17

(Figure by author. Source material from PLOS Neglected Tropical Diseases,

http://journals.plos.org/plosntds/s/journal-information, Accessed 5/4/14, WHO, 2013b)

PLOS has more reason to have a wide scope as an academic endeavour, where there will be public health and biological similarities across a wide range of diseases. The main restriction is the 'big three' being excluded, as there exists many other outlets for them.

To conclude this section, the variation in the number of diseases is representative of how NTDs are diversely described. Therefore the NTD label is not a purely biomedical description, as it is related to several social characteristics, such as poverty, stigma and voicelessness. I will go into more detail on categorization in the next section. Teasing out ideas about why certain categories or characterizations are used will provide insight about the 'claims-making' of policy problems (Conrad and Barker, 2010, p. S68). NTDs can thus be understood through other groupings than individual diseases. The different ways to divide up these diseases put forward rationale for disease inclusion. What these sub-groupings of NTDs say about the criteria determining which diseases are included and why will be discussed next.