Neglected tropical diseases

Address to the WHO Global Partners Meeting on Neglected Tropical Diseases

Dr Margaret Chan
Director-General of the World Health Organization

Excellencies, distinguished ministers of health, representatives of industry, colleagues in health and development, ladies and gentlemen,

This meeting – the first event of its kind – marks a turning point in the long and notorious history of some of humanity’s oldest diseases.

Gathered in this room are scientists who have spent their careers unravelling the complexities of these diseases.

Political leaders and ministries of health in endemic countries are present, demonstrating the level of commitment to diseases that almost exclusively affect poor and powerless people.

Development agencies, foundations, and implementing agencies are likewise represented. Your sustained support is a sign of our shared concern and our solidarity in matters of health. The burden imposed by these diseases, measured in terms of human misery alone, is unacceptable. We are committed to take action.

Industry is present. Your donations of drugs and other support opened an opportunity which public health has seized.

Your engagement has given us the tools to take action on an unprecedented scale. We have set ambitious goals and supported these with technical strategies for implementation.

Together, we are upholding a fundamental principle of health development: equity. Access to life-saving and health-promoting interventions should not be denied for unfair reasons, including an inability to pay.

We welcome other UN agencies. These diseases have international importance in sectors well beyond health.

Finally, we can welcome the World Bank and the development banks of Africa and Asia. There are economic consequences as well. We have solid evidence that these diseases hold back economic development in many significant ways.

I have described this meeting as a turning point. Why have these diverse interests converged in this room today? This is indeed a prestigious gathering for diseases historically prone to neglect!

I can offer a few explanations. One concerns the altered landscape of public health at the start of this century.

In just the past decade, health has achieved unprecedented prominence as a key driver of socioeconomic development. This prominence is formally expressed in the Millennium Development Goals, which recognize the two-way link between health and poverty, and give health development a central role to play.

The neglected tropical diseases express this link between health and development in an explicit, almost visual way – a way that is more compelling than statistics alone.

Conditions of poverty perpetuate these diseases, while the health impact of these diseases perpetuates poverty. This strong association with poverty is readily apparent from just a few examples. Some forms of African sleeping sickness and leishmaniasis are 100% fatal if not detected and treated in time. All of the other diseases debilitate, blind or maim, permanently curtailing human potential and impairing economic growth.

This is not difficult to understand. People whose limbs are deformed, and people who have been blinded by disease will not contribute fully to society and economies.

The drain on productivity is enormous. More than one billion people are affected. These people are a double burden for society. They cannot work to full capacity, and they require chronic care.

The costs of care can bankrupt households. Stigma and social isolation, especially for women, compound the misery and further embed people in poverty.

These diseases are also a burden for health systems. For many other infectious diseases, management is an intermittent emergency. The patient either survives or dies. This is not the case for these diseases, where the misery is prolonged.

Hospitals are burdened by patients whose internal organs have been permanently damaged by parasites. For some severe consequences of Chagas disease, the only truly effective treatment is a heart transplant. Surgical treatment of advanced Buruli ulcer requires weeks – if not months – of hospital care.

The burden of these diseases on a population can increase dramatically when an epidemic-prone disease of poverty, like cholera, causes explosive outbreaks.

This clear association with economic burdens has proved important in a climate of international commitment to poverty reduction. It has given these diseases an added dimension, and it has elevated their standing on the development agenda.

But it took more than an association with poverty to bring us to this room. There are other reasons why these diseases, so long ignored, are now receiving the attention they deserve. The prospects for reducing the enormous burden caused by these diseases have changed dramatically in just the past few years. We can identify a succession of well-planned actions, firmly rooted in evidence, that paved the way forward. These actions hold lessons for other areas of public health, and deserve a brief review.

First, a major step was to view these diseases as a group. This makes practical sense in operational and strategic terms. Strongly associated with poverty, these diseases frequently overlap geographically, with as many as six major diseases present in large parts of the world. Although medically very diverse, all of these diseases thrive under conditions of poverty and filth. They tend to cluster together in places where housing is substandard, drinking water is unsafe, sanitation is poor, access to heath care is limited or non-existent, and insect vectors are constant household and agricultural companions.

This geographical overlap means that people are often affected by more than one disease. It also means that strategies developed to deliver interventions for one disease can rationally be used to deliver interventions for others. This opens opportunities for integrated approaches, for simplification, cost-effectiveness, and streamlined efficiency.

We must not forget: we are dealing with neglected populations as well as neglected diseases. These people usually live in areas not covered by formal health services, and are notoriously difficult to reach.

When these diseases are viewed together, we gain critical mass. We get a better grip on the scale of the economic and social as well as the health burdens. Arguments for giving these diseases higher priority become more powerful, more persuasive. As yet another advantage, grouping these diseases together creates opportunities for the sharing of innovative solutions, especially as most control programmes face similar operational constraints.

For example, the dose pole was pioneered by the onchocerciasis control programme as a way to determine drug dosage, by height, for ivermectin. This innovation is now being used for schistosomiasis control, where praziquantel is administered in remote settings by non-specialized staff.

As a group, these diseases can participate in a shared momentum, where success for one disease spills over to benefit others. The eradication of guinea worm disease is now in sight despite the absence of a vaccine or curative drugs.

This success shows the feasibility of behavioural change in remote rural areas and the power of education to achieve this change. This is a strong message for many other health initiatives. Behavioural change is feasible and health education works, even in poor and illiterate villages. As a second step forward, expert consensus on control strategies was reached, and this carries weight. The first Berlin meeting on neglected tropical diseases, held in December 2003, was a stock-taking event, an inventory of needs, potential, and impediments to success.

At that time, the very low place of these diseases on national and international development agendas was identified as the principal reason so little progress was being made – despite the availability of powerful interventions.

Sixteen months later, when the second Berlin meeting was held in April 2005, the reasons for this neglect had been addressed, the arguments were ready, and the stage was set for action. Associated as they are with extreme poverty, these diseases share common determinants and must overcome similar obstacles to control. It thus makes sense, in an action-based strategy, to group the diseases according to shared operational and programmatic needs.

Two broad groups of disease were defined at the second Berlin meeting. The first includes diseases having rapid-impact interventions: drugs so safe and so powerful they can be administered to all at-risk populations. The emphasis here is on morbidity control, reducing the pool of human infection, and thus reducing levels of transmission.

This was a breakthrough, made possible by good drugs supported by industry donations. The option of mass preventive chemotherapy obviates the need for case finding and diagnosis. It greatly simplifies operational demands and opens the way for integrated approaches.

This is a population-wide approach: no one is excluded for unfair reasons. Nor is poor access to health services an absolute barrier. Many of these control strategies require only once-yearly contact with health services.

The second group includes more challenging diseases – the diseases that cannot be treated under a tree.

For diseases like African sleeping sickness, leishmaniasis, Chagas disease, and Buruli ulcer, the focus is on better case detection and clinical management. Dramatic steps forward must await the development of better diagnostics and drugs. These must be affordable and suitable for use under field conditions.

Ladies and gentlemen,

The next step came last year, when WHO and multiple partners launched an integrated strategy for preventive chemotherapy for four of the highest-burden tropical diseases: lymphatic filariasis, onchocerciasis, schistosomiasis, and soil-transmitted helminthiasis. Blinding trachoma may also benefit from this approach.

Viewing these diseases as a group and getting consensus on control strategies has been extremely important. It has moved these diseases from the debit to the credit side of the public health balance sheet. Instead of being seen as a permanent burden to be endured – the inevitable companions of inevitable poverty – these diseases can now be viewed as an opportunity for improving the lives and the productivity of more than one billion people.

As a third contributing factor, recent research has demonstrated the much larger significance of these diseases. Their impact on productivity has long been known, but remained poorly quantified until very recently.

For example, in 1949, a year after WHO was established, a first expert consultation on schistosomiasis was held. The experts noted that this disease affects the physical and mental development of children and greatly diminishes the strength and productive power of adults. As they further concluded: it does so in ways that markedly diminish food production. Since then, evidence of the enormous economic consequences of these diseases, which extend far beyond the costs of care, has grown. These figures, such as a billion dollars lost each year because of lymphatic filariasis in India alone, have great persuasive power when priorities are set and funds are allocated nationally and internationally.

The other side of the economic argument has also received attention in recent years. Economists have welcomed rapid impact interventions as bringing exceptionally high returns on investment. They are cost-effective, improve health, increase worker productivity, improve educational outcomes, and expand the domestic pool of resources. All of these factors contribute in well-documented ways to economic growth.

Persuasive arguments have come from additional lines of evidence. Research continues to reveal the intricate damage caused by these diseases. The subtle morbidity they cause – the excruciating pain, fatigue, and impaired cognitive function – are now better understood and appreciated.

These effects have an immediate and profound impact on agricultural productivity and educational outcomes. Such findings make these diseases important for other development sectors, including agriculture and education.

Research has also demonstrated a surprising number of ancillary benefits of preventive chemotherapy: improved micronutrient uptake and nutritional status, better cognitive performance, and improved childhood growth. Moreover, mass campaigns have completely eliminated some dreaded parasitic skin diseases. This unexpected benefit has increased public perceptions that these drugs are beneficial. It has also made populations receptive to subsequent campaigns.

With these various arguments in their favour, the neglected tropical diseases have arrived. They have moved into the mainstream of development thinking.

Having done so, control of these diseases now faces at least two of the most pressing problems confronting public health today. These are the management of partnerships and the strengthening of health system capacity.

When strategies for the integrated delivery of interventions were discussed at the second Berlin meeting, a question was raised: won’t this increase the burden on the district health system?

The answer was straightforward: the burden is already there. In some districts in Africa, as many as 15 different agencies are implementing programmes, without coordination and sometimes using different drugs and treatment regimens.

This is a problem that must be addressed. Part of the responsibility rests with donors and implementing agencies. There has been much recent debate about effective aid, about the new architecture for public health. We must never forget: an architecture rests on a foundation.

Decades of experience have taught us that activities undertaken by external agencies must be firmly rooted in national capacities and closely aligned with national priorities. This is the only sure route to sustainability.

Let me repeat: our mandate must come from ministries of health. It is good to have so many health ministers present in this room and to know that these diseases are receiving priority.

WHO also has an important responsibility. In our role as the leading technical authority on health, we can set the control strategies and define best technical practices. This is one way to better align the work of partners with international standards, strategies, and recommended practices.

Evidence has great strategic value. Last year’s manual on integrated preventive chemotherapy is strongly evidence-based. It also gives national authorities a flexible menu of options, so that recommended drug regimens can be adapted to local capacities and epidemiological conditions. This is important. WHO can propose strategies and best practices, but should not impose them. Countries must be the command centre, fully in charge of what is happening within their borders.

As a second major challenge, control strategies must address the weaknesses, in nearly all developing countries, of delivery systems. Here is the central dilemma we face. Multiple partnerships have formed to deliver specific health outcomes.

The ability to deliver these outcomes depends on a functioning health system. Yet the strengthening of health systems is seldom the core purpose of these partnerships.

If we want improved health to work as a poverty-reduction strategy, we must deliver interventions to the poor. Here is where we frequently fail. Here is where greater innovation is needed. All the donated drugs in the world will not do us any good in the absence of systems for their delivery to those in need.

I look to this group of diseases to pave the way forward on this important issue. I know you have found ways to use existing delivery systems, such as schools, in efficient and cost-effective ways.

We know, too, that immunization programmes – which often achieve the highest coverage of hard-to-reach populations – are beginning to distribute packages of interventions, including bednets for malaria and de-worming tablets for parasitic diseases.

The Berlin meetings have addressed this issue and have pointed to the importance of demand-led initiatives, in which communities take charge, in line with their perceived needs and priorities. Here, this group of diseases has yet another advantage: they are universally dreaded by populations.

Prevention and care are highly desired. Imagine the impact when a young woman with leprosy is told she can be fully cured, can marry, have children, and will not infect others. Just imagine the impact.

Many interventions bring rapid physical relief, which stimulates acceptance and further demand, even when the disease itself is poorly understood. It is this bottom-up demand that ultimately puts pressure on the political and health systems to deliver in sustainable ways, in line with population needs.

We have seen this happen with onchocerciasis, which began as one of the most vertical programmes imaginable: helicopters dropping insecticides out of the sky!

When the disease burden was sufficiently diminished, onchocerciasis control became a horizontal programme, operating much in line with the principles of primary health care.

Ultimately, this programme gave us the community-directed distribution strategy, another important innovation that has been extended to other diseases.

Although we do not yet have solid evidence, it is logical to assume that mass delivery of high-quality drugs will spur improvements in at least some parts of the health system. I am thinking here of drug procurement, storage, and transportation systems, of record keeping, inventories, evaluation, and monitoring. There are certainly other areas.

I know that several of these issues will be addressed when the working groups meet tomorrow. I look forward to your deliberations.

In conclusion, I want to return to my initial statement. This meeting is a turning point in the long and notorious history of some of humanity’s oldest diseases. Historically, these diseases – so strongly tied to poverty – have gradually vanished from large parts of the world as incomes increased and standards of living and hygiene improved.

Today, we no longer have to wait for these diseases to gradually disappear. We no longer have to wait for gradual improvements in housing, water supply, sanitation, and other basic infrastructures to take place. We can act right now to deliberately push these diseases back.

This is why this moment in history is different. The relationship between these diseases and poverty works two ways. We can turn the conventional formula around. We have the tools to control these diseases and, in so doing, we can reduce poverty.

Populations left behind by socioeconomic progress are in dire need of safe water and adequate sanitation, better access to health services, more opportunities for education, and improved nutrition. However, they also need to be freed from the burden of disabling and debilitating infectious diseases.

For the first time, we have a head-start on these ancient companions of poverty. For the first time, more than one billion people left behind by socioeconomic progress have a chance to catch up.

I believe this is our shared ambition.

I thank you for your attention and wish you a most productive meeting.

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