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Neglected diseases: Teach or treat?

Scientists are taking the debate over how to address neglected tropical diseases to the pages of PLoS Medicine, with one camp arguing in favor of more drug development, and another pushing for more funding and research on public health strategies such as sanitation and education. In 2005, researchers coined the term "neglected tropical diseases" to refer to thirteen diseases primarily occurring in rural, poor areas that have been largely ignored by policymakers and public health officials. Thes

By | May 18, 2010

Scientists are taking the debate over how to address neglected tropical diseases to the pages of PLoS Medicine, with one camp arguing in favor of more drug development, and another pushing for more funding and research on public health strategies such as sanitation and education. In 2005, researchers coined the term "neglected tropical diseases" to refer to thirteen diseases primarily occurring in rural, poor areas that have been largely ignored by policymakers and public health officials. These diseases, including sleeping sickness, river blindness, hookworm infection and more, traditionally fall second in attention and funding to "the big three" -- HIV/AIDS, malaria, and tuberculosis.
A mass drug administration in Mali
Image: www.neglecteddiseases.gov,
Albis Cabrelle
In the last five years, however, neglected tropical diseases are have experienced a hike in funding from private and government sources, including a linkurl:recent boost;http://www.neglecteddiseases.gov/ from the administration of U.S. President Barack Obama. But there is disagreement about how that money should be used. In a series of three opinions published together in a paper this week in PLoS Medicine, researchers examine past and present ways of tackling neglected tropical diseases (NTDs) and come to very different conclusions about which are the most promising. linkurl:Jerry Spiegel;http://www.ligi.ubc.ca/?p2=/modules/liu/profiles/profile.jsp&id=13 and colleagues at the University of British Columbia argue that there has been an over-reliance on biomedical approaches to NTDs, and research has largely ignored the socio-environmental roots of diseases, including sanitation, access to clean water, community education, and more. "Health is far more than a biomedical challenge," said Spiegel, director of global health at the Liu Institute for Global Issues in Vancouver, and a professor at UBC. A second opinion, written by Burton Singer of the linkurl:Emerging Pathogens Institute;http://www.epi.ufl.edu/ at the University of Florida, agrees with this assessment, arguing that there are many examples of the "over-medicalization" of NTD control strategies, citing the primarily drugs-only efforts to treat schistosomiasis and hookworms. Such programs don't prevent the reworming of the same individuals, argues Singer, and funds and support can fade away: The loss of a 10-year World Bank Loan Project for schistosomiasis in China in 2001 resulted in re-emergence of the disease in some areas. "These programs amount to establishing a chain of dependence on drugs with no terminal horizon in sight," he writes. But to linkurl:Marleen Boelaert,;http://www.itg.be/itgtool_v2/PersonalPages/PersonalPage.asp?CID=34&L=E an epidemiologist at the Prince Leopold Institute of Tropical Medicine in Antwerp, Belgium, who was not an author on any of the opinions, the picture is more complex. "They are right to say that social-economic context is important and that health systems are crucial for control, but I would not push it so far to say there is too much attention on drug development. It's not true," she said. Indeed, an opposing viewpoint printed in the same paper argues that few other NTD interventions rival the success of drug distribution. "We have proof-of-concept that these mass drug administration approaches work," said linkurl:Peter Hotez,;http://www.gwumc.edu/microbiology/faculty/hotez.htm author of the opinion and president of the Sabin Vaccine Institute in Washington, D.C. as well as a professor at George Washington University. "We've seen the impact." Since the 1970s, for example, a program providing drugs for river blindness has protected over 150 million people from blindness and eliminated the disease in Mali and Senegal, the authors cite. Hotez and colleagues suggest that drugs are the fastest, cheapest way to treat and control NTDs, and one of the greatest public health challenges over the next decade will be to accelerate the expansion of such drug programs. An integrated approach -- bundling existing mass treatments for seven NTDs causing 90 percent of the global burden and implementing them simultaneously -- would make what little money there is for NTDs go a long way, said Hotez. Individuals could be treated with an integrated chemotherapy for as low as $0.50 per year. "It's one of the best buys in public health," he said. "That's a fact," said Boelaert. "In the short term, [administering drugs] is the cheapest option. But in the long term, it is difficult to sustain these programs. Re-infection comes back." So the final solution will most likely be multi-faceted, she added. With that idea in mind, Spiegel and colleagues suggest an offset, like a carbon offset, should be taken from any drug funding earmarked for NTDs and used to address social, environmental, and health system factors. Since companies tend to invest in drug development because of its promise of economic return, these offsets would help channel funds to other important social aspects of the diseases. In the end, there is no debate, argued Boelaert -- one strategy alone won't solve the problem of NTDs. "Only drugs or only spraying is not sustainable," she said. "A responsible government will provide both. If not, you will never get rid of these types of diseases." Read the full debate at linkurl:PLoS Medicine.;http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000255 J.M. Spiegel et al. "Which new approaches to tackling neglected tropical diseases show promise?," PLoS Medicine 7(5):e1000255.
**__Related stories:__***linkurl:Stopping hookworm;http://www.the-scientist.com/article/display/53318/
[1st July 2007]*linkurl:Taking Aim at Neglected Diseases;http://www.the-scientist.com/article/display/15523/
[6th June 2005]*linkurl: Home-Base Biotech;http://www.the-scientist.com/article/display/56260/
[1st January 2010]

Comments

Avatar of: Ellen Hunt

Ellen Hunt

Posts: 199

May 19, 2010

The article appears to conflate diseases preventable with sanitation with those that aren't like sleeping sickness. \n\nInterestingly, sleeping sickness is treatable with injections of that laboratory staple of molecular biology, ethidium bromide at 1 to 5 mg per kilogram.
Avatar of: Joan Hanley-Hyde

Joan Hanley-Hyde

Posts: 4

May 19, 2010

Why can't training accompany the therapy? Certainly the providers of the therapy are more educated about the disease and can educate their patients about how to avoid re-infection, if it is possible. Otherwise, re-treatment is unavoidable.
Avatar of: Tarakad Raman

Tarakad Raman

Posts: 31

May 20, 2010

"NTD" is a convenient term, but we should guard against being misled into thinking that all NTDs can be tackled through a common strategy. NTD control strategies have to be devised separately for each disease. A judicious combination of "biomedical approaches" and consideration of "socio-environmental roots of diseases" is required.
Avatar of: CAMILO COLACO

CAMILO COLACO

Posts: 10

May 20, 2010

Would the development of vaccines be a viable option to tackle these diseases?
Avatar of: anonymous poster

anonymous poster

Posts: 1

May 21, 2010

I've noticed the need for a little better proofing of your stories.
Avatar of: PRASANTA GHOSH

PRASANTA GHOSH

Posts: 9

June 5, 2010

The fundamentals of the already known preventive practices for the control of the neglected tropical diseases (NTDs) should be promoted through public media like broadcasting, telecasting etc., more often with scientific illustrations that are easily understandable and appealing to the common folks. This would enable continued recapitulations and adaptation of the good practices on a sustainable basis. People tend to forget or avoid practicing the art. The usefulness of maintaining cost-effective standard operating procedures (SOPs) for maintaining good hygiene are not unknown for most of the NTDs. Practicing them all the time is lacking however. Such behavior promotes infection and re-infection. Continuously educating the target masses is a fundamental component for success. This task must be done uninterruptedly by the governments in poor countries, and if necessary, through legislations. This will work at least to minimize the spread.\n\nOnce infected, the curing of many of these diseases is not easy. There are effective drugs for the treatment for some of the diseases. But they are expensive and administration needs hospitalization (liposomal Amphotericin ?B for treating leishmaniasis for example), which tells upon the abilities of the resource poor societies, where the infections are more rampant. Death occurs in many such patients. Public infrastructure is grossly inadequate to deal with the situation.\n\nWe have been hearing about the need to prevent and conquer the NTDs for the last fifty years in India. There have been improvements in the situation, driven mostly by the discovery and utilization of appropriate and cost-effective sanitation technologies, hygienic practices, use of safer drinking water and distribution of free or subsidized medicines. But many of these public utility goods and services (Clean toilets, urinals especially for women and safe drinking water) are grossly in short supply even in the mega cities. We can construct, maintain and propagate these if there is a burning desire.\n\nGovernments have the lion?s share of responsibilities in this struggle. Besides strengthening the existing infrastructure, new avenues for conducting intensive research for developing more effective medicines and preventive practices have to be created. Funds for these have to be deliberately allocated at any cost. Many rich countries are also willing to provide some funds, access to which can be explored. Creative managers who have a flair for such public utilities should be in place. The funding philosophy for allocating resources from the private sectors for these activities do not fit in too well except for some philanthropic NGOs. Together, a judicious balance among preaching and practicing of the existing knowledge along with developing new therapeutics and practices through research, where the programs are piloted by governments shall have more mileage than taking any one-lane approach. \n\nIn the midst of multiple adversities and with severe resource constraints all around, the mankind has to travel many more miles to reach the stage of ?concurring? any of these conditions, especially in the poor countries. But efforts can?t stop and must be continued.\n

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