Neglected tropical diseases in the time of Dr Tedros
Editorial from Peter J. Hotez, published in Transactions of The Royal Society of Tropical Medicine and Hygiene, Volume 111, Issue 5.
The appointment of Dr Tedros Adhanom Ghebreyesus as the new WHO Director-General (DG) comes at a time when the geopolitical landscape for the control and elimination of the world's neglected tropical diseases (NTDs) may soon undergo some major shifts.
Indeed, the very act of transitioning to a new WHO DG historically has promoted global changes in how we approach these conditions. Under the leadership of JW Lee (2003–2006) and a committed group of NTD scientists, the modern framework of NTDs as a group of more than a dozen debilitating and poverty-promoting infections was established, and steps were taken to create a new WHO department specifically committed to NTDs (Figure 1).
The decade-long leadership of Margaret Chan (2007–2017) was similarly transformational. No one can doubt that Dr Chan made NTDs one of her highest priorities. In part through her advocacy and personal initiative, the NTD list expanded to 18 diseases, and there was unprecedented scale-up and integration in mass drug administration (MDA) for at least five of those diseases.
Over this period, the governments of the United States and United Kingdom took on large-scale financing for mass treatments of NTDs, while the London Declaration on Neglected Tropical Diseases reaffirmed the commitment of the major pharmaceutical companies to continue donating essential NTD medicines. The Special Programme for Research and Training in Tropical Diseases (TDR) regained its footing when it could have just as easily collapsed.
All in all, since the time when the current concepts of NTDs unfolded our community of NTD scientists and public health experts has benefited from two DGs who were thoughtful, interactive and highly communicative champions of these diseases.
Three successive WHO regimes and Directors General commit to NTDs. PC: preventive chemotherapy; TDR: the Special Programme for Research and Training in Tropical Diseases; UHC: universal health coverage.
As the new WHO DG, will Dr Tedros continue prioritizing and shaping the global NTD landscape?
There is no question that this new WHO regime will face numerous challenges, not the least of which are modest funds to promote and maintain the world's health. With a total budget of less than one-third that of the US Centers for Disease Control and Prevention (CDC), Dr Tedros can no longer afford an international health agency that aspires to be everything to everyone. He and his staff will have to make very difficult choices in the coming months.
On 3 July 2017, Dr Tedros made his opening remarks as he took the helm of WHO's leadership. In addition to reaffirming health as a human right, he outlined three major priorities, each of which we can link in some way to the NTDs. His first priority, ‘implementing leadership priorities and measuring results’, will focus on four areas, namely:
- universal health coverage (UHC);
- the health of children, adolescents and women;
- climate change.
With regard to UHC, NTDs will fit in nicely, but the new WHO leadership will still have some work to do. The good news is that overall we are reaching about 60% of the global population requiring access to MDA or what WHO terms ‘preventive chemotherapy’ (PC) for NTDs, including about this percentage for populations requiring PC for lymphatic filariasis and onchocerciasis, as well as about 60% of the school-aged population requiring mass treatment for soil-transmitted helminth infections.
But according to WHO we are still only reaching less than one-third of populations requiring trachoma treatments, and less than one-half of school-aged children needing treatment for schistosomiasis or preschool-aged children needing deworming for their soil-transmitted helminthiases.
A key challenge for UHC will be ensuring that WHO helps to close this gap, while also taking on or expanding MDA for two other NTDs, yaws and scabies. A comprehensive UHC program for soil-transmitted helminth infections, schistosomiasis, LF, onchocerciasis, trachoma, yaws and scabies would also go a long way towards simultaneously fulfilling priority focus areas of UHC and children, adolescents and women.
For the NTDs, WHO will need to expand UHC beyond just the PC diseases. For example, still today less than 1% of the 6–7 million people living with Chagas disease have access to diagnosis and treatment, and now we have an explosion in the number of cutaneous and visceral leishmaniasis cases due to ongoing wars in the Middle East, Central Asia and East Africa, in which refugees fleeing conflict zones are similarly denied access to treatment.
Another major priority for Dr Tedros, climate change, is similarly producing important new shifts in NTDs, possibly including a dramatic rise in arbovirus infections such as dengue, Zika virus infection and chikungunya in the Americas, and a similar rise in vector-borne diseases in southern Europe and the Middle East. However, climate change is not acting alone, but instead operates together with other modern Anthropocene forces such as human migration, urbanization, deforestation and human conflict to promote NTD emergence.
A second major priority announced by Dr Tedros includes ‘delivering results, value for money, efficiency and earning trust’. Along these lines, he proposes to tap the Global Policy Group ‘in order to have shared vision and accountability at all levels’. A mostly untapped policy for WHO is the concept of ‘blue marble health’ which finds that today most of the world's poverty-related neglected diseases and NTDs actually strike the poorest people who now live in wealthy G20 economies, ‘the poorest of the rich’.
WHO has an extraordinary opportunity to work with G20 Sherpas (emissaries) and at future summits to get a greater buy-in among the G20 nations that goes beyond just the US, the UK and some European governments. My use of the term ‘buy-in’ is both figurative and literal. If we are to achieve success in global NTD control we are going to need all of the G20 nations to financially step up and support mass treatments, while simultaneously funding urgently needed global health research and development.
Still another phenomenon being increasingly seen within the G20 and elsewhere is an overlap between NTDs and non-communicable diseases such that new co-morbidities are appearing. A good example is the severe and high mortality dengue seen now in patients with underlying hypertension or diabetes. This new NTD-NCD access will also become a new and important priority for Dr Tedros.
According to Dr Tedros his final high-level priority will be ‘reinforcing a talented, motivated and engaged staff’. Certainly, this is a cause that everyone can rally around. We are entering a second decade of WHO's historic and substantive commitment to NTDs, and recognize that a strong and empowered WHO Department of NTDs and its regional offices remain absolutely vital to our collective successes.
Dr Tedros has stated, ‘we have a historic opportunity to make transformational improvement in world health’. I am sure our NTD community of scientists and public health heroes will agree.
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