July 2013 Working Paper 03 Why neglected tropical diseases matter in reducing poverty Fiona Samuels and Romina Rodríguez Pose • Neglected tropical diseases (NTDs) have a direct impact on the achievement This and other Development of the Millennium Development Goals (MDGs). Without addressing these Progress materials are available at Key diseases, the broader aim of poverty alleviation is unlikely to be achieved. developmentprogress.org messages • Straightforward and highly cost-effective strategies are available to control Development Progress is an ODI project and eventually eradicate or eliminate NTDs. that aims to measure, understand and communicate where and how progress • Success in controlling, eliminating or eradicating NTDs depends on has been made in development. partnerships between multiple constituencies that enable countries to adapt international guidelines to local contexts, integrate NTD programmes into ODI is the UK’s leading independent think tank on international development health systems and engage communities in implementation. and humanitarian issues. Further ODI materials are available at odi.org.uk Introduction indicators specific to them (Molyneux, 2008). While neglected tropical diseases (NTDs) One possible explanation for have been recognised for centuries – international disinterest is that NTDs indeed as ‘biblical plagues’ – NTDs have, almost exclusively affect the developing as the name implies, remained below the world (though this is also true for malaria) radar of most international and national and are not likely to spread far beyond; policy-makers. indeed, many NTDs have disappeared This relative neglect can be seen in completely in the developed world due examining the Millennium Development to improved hygiene and sanitation Goal (MDG) framework: while NTDs standards. Similarly, they tend to affect the are supposedly included in MDG 6 under poorest people, who have little political ‘other diseases’, they are largely forgotten voice or lobbying capacity (World Health in favour of the HIV and AIDS, malaria Organization (WHO), 2010). They are also and tuberculosis (TB) parts of MDG 6, largely chronic conditions, which, with few Health extension workers from Gondar Zuria Woreda, Maksegnit town, Ethiopia. Photo © as evidenced by the fact that there are no exceptions, are not prone to epidemics. UNICEF Ethiopia. developmentprogress.org However, over the past decade, there has been a resurgence of interest in NTDs arising from an increasing Box 1: Common features of NTDs awareness that NTDs, which are silently affecting the • A proxy for poverty and disadvantage. poorest billion people (WHO, 2010), represent an impediment to achieving wider human development • Affect populations with low visibility and little outcomes (for example, improved maternal and child political voice. health, and food and nutritional security). Additionally, • Do not travel widely. NTDs both affect and are affected by many of the other • Often overlap geographically. areas covered by the MDGs. Because of linkages with the other MDGs, and as • Cause stigma and discrimination, especially for NTDs are beginning to be discussed as part of the girls and women. post-2015 framework, ODI decided to include research • Have an important impact on morbidity and 1 in this area as part of the Development Progress project. mortality. Through better understanding country-level progress • Are relatively neglected by research. made in NTDs, alongside research on an area that has received greater attention, such as maternal and child • Can be controlled, prevented and possibly health, we aim to inform policy in countries facing eliminated using simple, effective and feasible similar challenges. solutions. Preliminary background research undertaken Source: WHO (2010) to identify countries showing relatively high levels of success in addressing NTDs uncovered some characteristics that appear to be critical for a country of the affected countries, and all low-income countries are to achieve progress. These are not necessarily only affected by at least five NTDs (WHO, 2010; Jannin and applicable to NTDs, but apply also to broader health Savioli, 2011). Up to 90% of the global NTD burden is issues in resource-constrained settings, as evidenced explained by five of these diseases (see Table 1). in earlier Development Progress case studies2 and preliminary findings from the NTD case studies in Sierra Table 1: Five main NTDs with prevalence and Leone and Cambodia. population at risk In this paper, we explore how NTDs constitute a critical area for improving health-care outcomes more Diseases Prevalence (millions) Population at risk broadly. Soil-transmitted helminth infections: • We outline what NTDs are and how they are treated. ascariasis 807 4.2 billion trichuriasis 604 3.2 billion • We explore why they are important for progress hookworm 576 3.2 billion in health and broader well-being, using the MDG Lymphatic filariasis 120 1.3 billion framework as a structure for analysis. Onchocerciasis 37 90 million • We reveal some of the factors that we see as critical Schistosomiasis 207 779 million to controlling and eventually eliminating NTDs, and Trachoma 84 590 million discuss some challenges going forward. Source: Hotez et al. (2007) Note: The other 12 diseases, representing 10% of the disease burden, are: dracunculiasis, cyst- icercosis, echinococcosis, food-borne trematodes infection, dengue, rabies, leishmaniasis, human What are NTDs? African trypanosomiasis, Chagas disease, leprosy, Buruli ulcer and endemic treponematoses. NTDs are a group of 17 diseases that have been recently branded under the NTDs label in spite of being widely How can we treat NTDs? diverse in terms of their distribution, epidemiology, transmission, vector involvement, zoonotic aspects, The WHO recommends a combination of five strategies pathology and requirements for prevention and control. for the prevention and control of NTDs, which are applied The WHO has listed them together because they share a according to the epidemiology of the specific NTD. set of common characteristics (see Box 1). Many of the The strategies are preventive chemotherapy (PCT); NTDs have unpronounceable names, which has in part led intensified case-management; vector control; safe water, to them being branded ‘NTDs’ as a ‘useful form of sanitation and hygiene; and veterinary public health. shorthand’ to help raise their profile in the international The unprecedented decision of some pharmaceutical agenda and mobilise resources (WHO, 2010). companies to donate ‘as much drugs as needed for as NTDs are endemic in 149 countries. Low-income and long as needed’ in order to help eliminate NTDs3 has low-middle-income countries represent more than 70% changed the NTDs landscape by making the drugs 02 Development Progress working paper NTDs proliferate in areas where large numbers of people do not have access to adequate health care, clean water, sanitation, housing, education and information. Bo District, Sierra Leone, where significant strides have been made in tackling NTDs across the country. Photo © Romina Rodríguez Pose/Overseas Development Institute. accessible for the poorest countries, with PCT becoming agriculture, irrigation and the environment. the most common approach to treating the five major • Finally, veterinary public-health measures are also diseases. crucial in tackling NTDs since much of the morbidity and mortality resulting from NTDs arises from • PCT involves a single dose of medication once or zoonotic diseases (for example, anthrax, bovine twice a year, usually administered through large- tuberculosis, brucellosis, cysticercosis, echinococcosis, scale distribution of medicines, known as mass drug rabies and zoonotic trypanosomiasis). administration (MDA). For MDA to be successful, not fewer than 65%–80% of the total population living in endemic areas have to take the drug. As such, it is often Why NTDs are important for progress in administered by community volunteers and teachers, allowing delivery to large numbers of people also in health and their linkages to other MDGs remote areas (WHO, 2010).4 • Intensified case-management involves caring for NTDs are found and proliferate in areas where large infected individuals and those at risk of infection. numbers of people do not have access to adequate health This intervention is the principal strategy for care, clean water, sanitation, housing, education and controlling those NTDs for which no preventive information. Arguably, therefore, by treating the NTD, medicines are available, such as Buruli ulcer, Chagas we can accelerate progress in a range of complementary disease, human African trypanosomiasis, leishmaniasis, development areas, such as poverty, nutrition, water and leprosy and yaws.5 sanitation, women’s empowerment and education. • The control of vector-borne diseases that are NTDs have wide cross-cutting and cross-sectoral transmitted by insects, snails or crustaceans often linkages and effects; they are linked to almost all requires the use of pesticides. MDGs, and efforts to ease their impact represent a • Vector management is strengthened through provision largely unexploited opportunity to alleviate poverty and of safe water, sanitation and hygiene and close have a direct impact on the achievement of the MDGs. collaboration within sectors responsible for health, This section explores the linkages between NTDs and Why neglected tropical diseases matter in reducing poverty 03 other areas of development using the