Reaching the people left behind: A neglected success
Dr Margaret Chan
Director-General of the World Health Organization
Keynote address delivered at the Prince Mahidol Award Conference
Your Royal Highness,
Prince Mahidol Awardees,
colleagues, ladies and gentlemen,
Thank you for inviting me to address this distinguished audience. The first WHO Executive Board under my responsibility closed this week. As I speak to you, many urgent health problems are fresh in my mind, as is the great spirit of optimism and solidarity we see today in public health.
Our challenges are great, but so is our determination to work together to find solutions and achieve results. We are doing so for the neglected diseases of neglected populations, as I will be discussing.
I received the prestigious Prince Mahidol Award in 1998. That was a year after Hong Kong successfully controlled the world’s first documented outbreak of human cases of H5N1 avian influenza. At that time, we had 18 cases, of which 6 were fatal. That seems like a small number, but it was sufficient to alarm the whole world.
We knew little about this disease beyond the fact that it jumped from chickens to humans, and caused very severe respiratory disease. We took drastic measures to control the disease in poultry, and these measures ended the risk to human health. Some experts believe we may have averted a pandemic at that time.
Since that experience in Hong Kong, I have moved on in my career. So has this H5N1 virus. The virus is now firmly entrenched in birds in large parts of Asia. Our chances of quickly ending the threat to human health have faded away.
The recent behaviour of this virus has brought the world closer to another influenza pandemic than at any time since 1968, when the last pandemic began. All agree that an influenza pandemic directly threatens national and international security.
The SARS outbreak of 2003 taught us how much our highly mobile, interconnected, and interdependent world has changed in terms of its vulnerability to shocks caused by a new disease. Governments at their highest level have expressed concern about the impact of an influenza pandemic on economies and business continuity as well as on health.
Many millions of dollars have been invested in preparedness measures. This is another sign of great concern at the highest level. It also shows us how resources become available when countries are directly threatened by a disease that can invade their territories and disrupt domestic affairs.
Your Royal Highness,
You have selected neglected diseases as the topic for this conference. You have gone a step further by stressing the need to reach neglected populations. This underscores your emphasis on access to essential health technologies. To me, this indicates a concern about unmet needs and a desire to correct this situation through the delivery of essential interventions. I share this view most profoundly.
I will speak about neglected tropical diseases as a way of addressing two main questions.
First, what does access to essential medicines mean for the control of diseases that affect almost exclusively very poor populations? What does this mean in terms of health? What does it mean for the larger issues of socioeconomic development?
Second, what forces need to come together to make this access possible? Let us first look at what neglected tropical diseases mean – where they occur, why they occur, the damage they cause, and why we should care. Throughout the developing world, socioeconomic progress is impeded by these ancient and entrenched diseases. They maim, debilitate, blind, disfigure, and kill. They permanently diminish human potential, and do so in large populations.
If emerging diseases, like SARS or pandemic influenza, are at the high end of the health and security agenda, the neglected tropical diseases are at the other end.
These are not new and frightening diseases. They are ancient. They do not flare up in outbreaks with high mortality. They do not grab the headlines. They do not travel abroad or threaten international security.
These are largely invisible diseases, occurring as they do in impoverished rural areas and shantytowns. They are rarely seen today in populations that enjoy good access to health services and a reasonable standard of living.
And these are silent diseases, affecting as they do populations with low literacy and little political voice.
The names of these diseases are difficult to pronounce: onchocerciasis, trypanosomiasis, lymphatic filariasis, schistosomiasis, soil-transmitted helminthiasis, and blinding trachoma.
The numbers affected by these diseases are difficult to comprehend. At least 1 billion people – one-sixth of the world population – currently suffer from one or more of these diseases. More than 40 million people are permanently incapacitated and disfigured by lymphatic filariasis.
In Africa alone, schistosomiasis affects at least 160 million people. Of these, at least 30 million suffer permanent, life-threatening complications.
Let me underscore a point I made earlier. The human suffering represented by these figures is enormously greater than that represented by the 270 cases of avian influenza reported globally over the past three years. But here is the difference: the neglected tropical diseases do not threaten international health and security. This is one explanation for the neglect.
The neglected tropical diseases are medically diverse in terms of their causes and pathologies. WHO treats these diseases as a group because they occur almost exclusively in impoverished populations – the people left behind by socioeconomic progress. In fact, the link with poverty is so strong that the prevalence of these diseases can serve as a proxy indicator of the level of a country’s socioeconomic development.
These diseases flourish in areas where water supply and sanitation are inadequate, nutrition is poor, literacy rates are low, health systems are rudimentary, and insects and other disease vectors are constant household and occupational companions. Not surprisingly, these diseases cluster together and frequently overlap wherever such conditions occur.
These diseases have consequences that go beyond their severe damage to health. Additional consequences range from the burden of home care for chronic disabilities to missed days at schools, lost months and years of agricultural productivity, inefficient land use, and food insecurity.
Some of these diseases impair childhood growth, intellectual development, and educational outcomes. Adults permanently disabled by blindness or limb deformities are not only disadvantaged themselves. They also become a social and economic burden in rural agricultural communities that eke out a living from subsistence farming.
Your Royal Highness,
Neglect of these diseases occurs at three main levels. At the national level, these diseases are hidden in remote areas and are poorly documented.
They are hidden for a second reason: stigma. Stigma keeps people –especially women – out of sight. It also discourages people from seeking care early in the disease course, when the chances of cure are greatest.
Second, neglected diseases lack visibility at the international level. Tied as they are to specific geographical and environmental conditions, they do not travel. They impair or permanently disable millions of people, but cause comparatively few deaths.
Third, these diseases have long been neglected by research and development. Industry has little incentive to develop drugs and vaccines for markets that cannot pay.
When inexpensive and effective drugs already exist and are available, delivery fails because patients cannot pay and because health systems are weak or non-existent. Let’s look at this dire situation in a more optimistic way. Think of the sheer scale of the opportunity. The potential of one billion people to live productive lives is permanently diminished by a limited group of overlapping diseases. Imagine the scale of the contribution to poverty reduction that control of these diseases could bring.
Thanks to recent developments in several areas, we are now in a much better position to seize this opportunity. While important constraints remain, the prospects for controlling some of the most burdensome neglected diseases, on a large scale and in sustainable ways, have never looked better.
Thanks to donations by industry, nearly all of these diseases can now be managed with robust, safe, and effective interventions. Well-defined strategies for their implementation have been developed and extensively tested.
In addition, recent research has greatly simplified control strategies for several of these diseases. This research has shown that available drugs are so safe and effective that they can be administered pre-emptively to all at-risk populations.
Preventive chemotherapy eliminates the need for individual case-finding and diagnosis. This approach usually requires only once-yearly contact with the health services and does not depend on highly trained staff.
As the most recent step forward, WHO has developed strategies for the integrated delivery of interventions for several overlapping diseases. This is a value-added approach that streamlines operational and programmatic requirements while amplifying the health benefits for target populations.
Recent research shows that some of the drugs bring added benefits, such as improved nutritional status and micronutrient uptake. These benefits support the very foundations of better health status in impoverished populations.
In a most welcome trend, public-private partnerships have formed to combat these diseases. Some aim to reduce levels of transmission to a point that can eliminate these diseases – the ultimate form of sustainability.
In many cases, ambitious targets are underpinned by research promoted over the years by the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases and its partners. This work increasing includes operational and implementation research aimed at improving access.
As part of these partnerships, industry is donating high-quality drugs in great quantities. Some of these partnership agreements provide for the donation of drugs wherever needed, in whatever quantity, as long as it takes to reach targets.
In still other cases, industry is donating millions of dollars to support WHO activities and build health infrastructure in affected countries. Industry is also conducting educational campaigns to reduce stigma, especially for leprosy, and thus encourage earlier reporting for treatment. This is good will, rather than good business for industry.
For me, this is all very good news. It shows how a sense of corporate social responsibility on the part of industry can be harnessed to make essential interventions accessible to populations who cannot pay.
It demonstrates appreciation for the role that disease control plays in socioeconomic development. And it demonstrates our solidarity in health – our shared responsibility to combat diseases, even when they do not directly threaten our collective security.
I will turn now to the second main question I want to address. What forces have converged to make this possible?
First is the availability of safe and highly effective drugs – the best drugs the world can offer. Second is the decision by the pharmaceutical industry to make these drugs available at no cost or at greatly reduced prices.
Third, we produced evidence showing the broad impact of these diseases. The fact that these diseases make many millions of people miserable is not, unfortunately, sufficiently persuasive. We needed to show the broader impact – on childhood development, educational outcome, productivity, and economies.
Fourth, we developed value-added strategies that showed how multiple causes of poor health could be addressed through a single programmatic approach, thus amplifying the impact. Smart, streamlined, integrated approaches have great appeal as well as great capacity to do good.
Finally, and perhaps most significantly, all of these factors helped put these diseases into the mainstream of efforts to foster development. The control of neglected tropical diseases is a pro-poor initiative, a poverty reduction strategy for the masses.
Your Royal Highness,
I subtitled this presentation, “A neglected success.” We have demonstrated success, but there are two important remaining areas of neglect we need to address.
The first challenge is to generate the resources needed to greatly expand population coverage. In this case, success needs to breed much more success.
Given the power of available interventions to prevent many of these diseases, intensified delivery may be the best route to a better life for many millions of people.
Second, we greatly need research and development for innovative new tools, particularly for diseases like African trypanosomiasis, leishmaniasis, and Buruli ulcer. While drug donation partnerships offer great hope, it should be noted that many of these drugs were already on the market for other indications.
The need for new tools applies to many diseases, including HIV/AIDS, tuberculosis, and malaria. While we can often hold infectious diseases at bay with existing tools, we need effective vaccines, better diagnostics, and better drugs to make truly dramatic progress.
We also need to keep ahead of the loss of front-line medicines when drug resistance inevitably develops.
I know that you will be addressing these issues today and tomorrow, and look forward to the results of your deliberations.