Through the delivery of extremely low cost treatments, these partnerships—in collaboration with WHO, health ministries in low-income countries, and several multinational pharmaceutical companies—have managed to control or eliminate river blindness in 11 African countries, allowing farmers to return to arable lands they had abandoned because of high rates of blindness in their communities. Similarly, treatment programs have eliminated LF in more than a dozen previously endemic countries and reduced the prevalence of schistosomiasis by up to 80 percent in eight African countries. Measured narrowly in financial terms, the internal rates of return for these programs have ranged as high as 30 percent.
One Pill to Cure Them All
Despite these enormous successes, we still have a long way to go to provide complete drug coverage for the billion or more people with NTDs. WHO estimates that treatment programs reach fewer than 10 percent of people suffering from intestinal infections and schistosomiasis.
Better organization and technology are part of the answer. WHO and other organizations have studied the simultaneous administration of many NTD drugs, and they are moving quickly to provide these drugs as a single package (sometimes referred to as a rapid impact package), which can cost as little as 50 cents annually. A number of African countries have already begun to integrate programs that target individual NTDs into a single program. Bundling reduces costs and the strain on otherwise overburdened health systems, as well as providing an opportunity to fold in other interventions, among them the delivery of antimalaria bed nets, childhood immunizations and nutritional supplements such as vitamin A.
Although the integration of NTD-control programs has been largely successful so far, it has also encountered some operational challenges, including an increased workload for community drug distributors and the lack of availability of some of the NTD drugs in certain places. Health workers have had to be vigilant in looking for signs of drug resistance.
Ultimately, these NTD-control programs will need more money. The U.S. and British governments have committed more than $400 million over the next few years to support integrated NTD control, but estimates suggest that controlling NTDs in the 56 endemic countries will require $2 billion to $3 billion for the next five to seven years. To make the case for better funding, some of the major public-private partnerships came together in 2006 to form the Global Network for NTDs, which works closely with WHO and its regional offices. Hosted by the Sabin Vaccine Institute, the network receives support from the Gates foundation and other private donors and works to support treatment programs for NTDs around the world through advocacy, policy and logistical efforts.
The Sabin Vaccine Institute has also established an international product development partnership to produce new vaccines for hookworm infection and schistosomiasis. A hookworm vaccine is now entering clinical trials, which is welcome news because of concerns that one of the drugs now in use for mass treatment is showing high failure rates, a sign that the parasite has become resistant. Sabin works with a spectrum of Brazilian research and development institutes and the Brazilian government. Brazil has the largest number of cases of these helminth infections in the Americas; these NTDs were originally introduced from the endemic areas of West Africa by the slave trade, making them living vestiges of slavery.
If fighting NTDs is so obvious and so cheap, why has it taken so long to act in a systematic way? That is not an easy question to answer. In the Millennium Development Goals for sustainable reduction of poverty, launched in 2000, the NTDs were lumped in an “other diseases” category, and it is hard to get people excited about “other diseases.” Moreover, the NTDs debilitate more than they kill, so that the big donor countries have chosen to focus primarily on HIV/AIDS, tuberculosis and malaria, which are fatal unless treated. Other development programs, viewing NTDs as a symptom rather than the disease, have preferred to concentrate on what they see as the underlying problems, such as poor sanitation, lack of access to clean water, and poverty in general. Those are laudable aims, but the empirical reality is that NTD drugs are the single most cost-effective way to improve the health, education and well-being of the world’s poor right now.