Lineamientos

If neglect is understood in how the policy problem of NTDs is defined, this is assisted through measurement of R&D investment (10/90 gap), and of disease burden (DALYs). Moving onto an understanding of neglect in the solutions, in terms of what interventions will make the most difference, it has been a historical legacy of neglect that vaccines and drugs have not been developed for some of the NTDs. Some of the existing drugs are old, in need of improvement, or need continuing research in case there is drug resistance.¹¹⁵

For example, successful drugs such as praziquantel, used to effectively treat the schistosomiasis parasite may now be developing resistance. Certainly penicillin, used to treat yaws, is at risk of resistance, with concerns also in the difficulty of refrigeration as well as training to administer in developing country settings (Broadbent, 2011, p. 55). Other strategies for addressing these diseases are available, either suggested as an alternative or alongside a drug-based strategy. Table 12 shows what strategies are recommended by the WHO for each disease. Also see Appendix 9 for an earlier and briefer list of NTDs control strategies by the All-Party Parliamentary Group on Malaria and Neglected Tropical Diseases (APPMG, 2009) and see the Appendix 10 for a comprehensive table of current strategies per disease.

115It was not until 2009 that NECT (Nifurtimox and Eflornithine Combination Therapy) was introduced to treat the early stages of human African trypanosomiasis, as first new improved treatment option in 25yrs for stage 2 of disease. The drugs that had been commonly used are pentamidine, which was discovered in 1940 and suramin to treat the rarer form of the disease, which was discovered in 1920 and can cause urinary tract and allergic reactions (WHO Factsheet N°259, 2015).

Table 18 Strategies by disease

(Compiled from information on CDC http://CDC.gov.org; DNDi http://www.dndi.org; WHO, 2015)

There are five NTDs (trachoma, lymphatic filariasis, onchocerciasis, schistosomiasis, and soil-transmitted helminths) that are being addressed primarily through Mass Drug Administration (MDA) of anthelminthics and antiparasitics, along with antibiotics. According to the NGO ENVISION: "(MDA) is the administration of drugs to entire populations, in order to control, prevent or eliminate common or widespread disease".¹¹⁶ MDA used to control NTDs has been hailed as an effective policy intervention, which the WHO describes as a ‘preventive chemotherapy’ to regularly and systematically administer medicines to populations who may either have an NTD or be at risk (WHO, 2012c).

It is a cheap form of treatment at 50 cents per person, according to the CDC, as "...one of the best buys in public health – with a low cost of about $0.10 to $0.50 per person/year and the benefit of helping prevent or treat several different diseases" (CDC, 2010, p.2). As Warren Lancaster, a senior vice president at NGO 'The End Fund' has put it: "for the donor community that's a very attractive proposition" (Interview with author, Lancaster, 2014). Similarly, Professor Alan Fenwick describes MDA at 50 cents per person as "...the best buy for public health"

(APPMG, 2009. p. 14), acting as a marketing tool to 'sell' an attractive solution. It proved to be a successful pitch for Fenwick, when the '50 cents per person' caught the eye of Alan McCormick, a Partner at global investment firm Legatum, following an interview Fenwick gave to the Financial Times in 2006:

dracunculiasis (1) safe drinking water, surveillance, awareness among affected and at-risk populations

"...a phrase from an interesting article on philanthropy implanted itself in his mind: that such treatable ailments ‘do not need innovation but simply modest funding and a little imagination in order to distribute drugs to those in need'... He was inspired by the idea that it might be possible to change the lives of millions, to free them from the burden of devastating illness, for as little as 50 cents per person".¹¹⁷

The result was the Legatum Foundation establishing 'The END Fund' as an NGO to finance control initiatives, and supplementing and creating new programs in a bid to control or eliminate the five most common NTDs. However despite the impact, the '50 cents per person' proposition is not problem-free. There is some worry about drug resistance from continued usage at this scale (Barry, Simon, Mistry, & Hotez, 2013) and acceptance by local communities dependent on perceptions and experiences.¹¹⁸

Another four NTDs are treatable either through antibiotics or antifungals (buruli ulcer, leprosy, yaws, and leishmaniasis). Still, environmental strategies are crucial for these diseases and are part of well-functioning health systems, including: information/education, clean water, sanitation, early detection/diagnosis/case management, surveillance, control of reservoir hosts, social mobilization and the strengthening of partnerships. For lymphatic filariasis (also known as elephantiasis) in addition to MDA, the WHO recommends an alternative and equally effective environmental strategy. This is the use of common table salt or cooking salt fortified with DEC (diethylcarbamazine) for one year in endemic regions, with vector control as a supplemental strategy. Some diseases are in fact better addressed with environmental-based strategies, replacing drug-based strategies or supplementing them. For example, safe drinking water through surveillance and awareness among affected and at-risk populations is the preferred strategy for dracunculiasis.

Still, the preferred strategy is changeable, dependent on resources, disease spread, and research developments. In the case of onchocerciasis, vector control had been successful in the past but was no longer considered feasible or cost-effective in the remaining APOC (African Programme for Onchocerciasis Control)¹¹⁹ countries, which is why MDA is now favoured. Also for the mosquito-spread diseases Chagas, dengue, and chikungunya, vector control is the main strategy. This is partly because no vaccine is available, so the strategy may change if one is developed, but also (in the case of Chagas and to some extent lymphatic filariasis) because clinical symptoms are often not present until the disease has advanced in adulthood, such that drugs are less effective and have side effects. Food hygiene and veterinary public health measures or animal management (e.g. deworming of dogs, vaccination of pigs) are the best

117The Legatum Group, http://www.legatum.com/philanthropy/investing-in-development/united-voices/, Accessed 4/30/16.

118Malaria Consortium, http://www.malariaconsortium.org, Accessed 2/4/14.

119The APOC programme has closed as of December 2015 and the establishment of a new regional entity is expected to support country programmes.

strategies for cysticercosis/taeniasis, rabies, echinococcosis, and foodborne trematodiases.

Although large-scale preventive chemotherapy in humans through MDA may also be required in endemic areas with high infection rates.

Through comparing environment-based and drug-based strategies a number of points are striking in highlighting the diversity of these diseases (See Appendix 11 for a full list of diseases and the strategies recommended):

1. The diseases that require a mainly drug-based strategy are limited to 10.

2. There is difficulty in developing vaccines/drugs for diseases with a mosquito vector.

Vector control strategies work best today but this may change and the development of vaccines needs to be considered against the amount of resources needed.

3. Food and animal related illnesses are overlooked when considering NTDs in policy, as they require social/cultural change.

4. A number of diseases are near elimination or eradication, requiring a large amount of resources (rather than disease control).

5. Some outlier diseases appear to allow for limited strategies of control.

I have shown that problem and solution definitions that are drug-based have 'policy appeal'.

Metrics identify the policy problem of NTDs through the 10/90 gap, which says R&D for new drugs is not being directed at the diseases of the poor, and DALYs, which says we should pay attention to chronic diseases of the poor, following cost-effectiveness drugs distribution with MDA. The metric of the '50 cents per person', presented by the NGOs such as 'The Global Network Against Neglected Tropical Diseases' and global commitments including the landmark 'London Declaration' meeting in 2012, emphasize MDA of drugs as a central strategy and encourage involvement of big pharma. These metrics present the degree of neglectedness to be on lack of R&D investment (10/90 gap), the disease burden not being recognized because of morbidity character of the disease (DALYs), and the success of low-cost-high-return interventions not known ('50 cents per person').

However, by returning to the 17 diseases and analyzing what are the preferred individual strategies to control and eliminate or eradicated the disease, the drug-dominant strategy unravels. As I have highlighted, drug-dominant strategies only apply to just over half of the diseases and some outlier diseases have very limited strategies for control. Furthermore, the technical challenge of developing vaccines or drugs for diseases with a mosquito vector is high, while vector control strategies may be effective. A number of diseases have had mixed strategies (both drug and environmental), which have been yielding results. Included here are diseases that are near eradication as a result of vector control, community-level programs and health education alongside drugs (guinea worm and yaws). These diseases now require

continued funding and resources, rather than new drugs or simply the implementation of existing drugs.