tag:theconversation.com,2011:/id/topics/neglected-tropical-diseases-9111/articlesNeglected Tropical Diseases – The Conversation2024-03-13T12:37:43Ztag:theconversation.com,2011:article/2218362024-03-13T12:37:43Z2024-03-13T12:37:43ZLeprosy cases are rising in the US – what is the ancient disease and why is it spreading now?<figure><img src="https://images.theconversation.com/files/581098/original/file-20240311-22-xteppq.jpg?ixlib=rb-1.1.0&rect=21%2C10%2C7167%2C4031&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Leprosy can be caused by two different bacteria, one of which was only identified in 2008.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/leprosy-bacteria-illustration-royalty-free-illustration/1193685361?phrase=leprosy&adppopup=true">Kateryna Kon/Science Photo Library via Getty Images</a></span></figcaption></figure><p><em>The word “leprosy” conjures images of biblical plagues, but the disease is still with us today. Caused by infectious bacteria, <a href="https://www.who.int/news-room/fact-sheets/detail/leprosy">some 200,000 new cases are reported each year</a>, according to the World Health Organization. In the United States, leprosy has been entrenched for more than a century in parts of the South where people came into contact with armadillos, the principle proven linkage from animal to humans. However, the more recent outbreaks in the Southeast, <a href="https://epi.ufl.edu/2023/10/16/leprosy-in-florida-medical-experts-monitoring-unusual-new-cases-of-hansens-disease/">especially Florida</a>, have not been associated with animal exposure.</em></p>
<p><em>The Conversation talked with <a href="https://www.ae-info.org/ae/Member/Schwartz_Robert">Robert A. Schwartz</a>, professor and head of dermatology at Rutgers New Jersey Medical School, to explain what researchers know about the disease.</em></p>
<h2>What is leprosy and why is it resurfacing in the US?</h2>
<p>Leprosy is caused by two different but similar bacteria — <em>Mycobacterium leprae</em> and <em>Mycobacterium lepromatosis</em> — the latter <a href="https://doi.org/10.1309/AJCPP72FJZZRRVMM">having just been identified in 2008</a>. Leprosy, <a href="https://www.cdc.gov/leprosy/index.html">also known as Hansen’s disease</a>, is avoidable. Transmission among the most vulnerable in society, including migrant and impoverished populations, remains a pressing issue.</p>
<p>This <a href="https://doi.org/10.1111/ijd.15998">age-old neglected tropical disease</a>, which is still <a href="https://www.who.int/news-room/fact-sheets/detail/leprosy">present in more than 120 countries</a>, is now a growing challenge in parts of North America. </p>
<p>Leprosy is beginning to occur regularly within parts of the southeastern United States. Most recently, Florida has seen a heightened incidence of leprosy, accounting for <a href="https://doi.org/10.1001/jama.2023.13938">many of the newly diagnosed cases</a> in the U.S. </p>
<p>The <a href="https://doi.org/10.3201/eid2908.220367">surge in new cases</a> in central Florida highlights the urgent need for health care providers to <a href="https://www.hrsa.gov/sites/default/files/hrsa/hansens-disease/hd-surveillance-form.pdf">report them</a> immediately. Contact tracing is critical to <a href="https://iris.who.int/bitstream/handle/10665/336679/9789290228073-eng.pdf">identifying sources and reducing transmission</a>. </p>
<p>Traditional risk factors include zoonotic exposure and having recently lived in leprosy-endemic countries. Brazil, India and Indonesia have each <a href="https://www.who.int/news-room/fact-sheets/detail/leprosy">noted more than 10,000 new cases</a> since 2019, according to the World Health Organization data, and more than a dozen countries have reported between 1,000 to 10,000 new cases over the same time period.</p>
<h2>Why was leprosy stigmatized in biblical times?</h2>
<p>Evidence suggests that <a href="https://doi.org/10.1556/oh.2011.29038">leprosy has plagued civilization</a> since at least the second millennium B.C. </p>
<p>From that time until the mid-20th century, <a href="https://doi.org/10.1038/jid.1953.65">limited treatments were available</a>, so the bacteria could infiltrate the body and cause prominent physical deformities such as disfigured hands and feet. Advanced cases of leprosy cause facial features resembling that of a lion in humans.</p>
<p>Many mutilating and distressing skin disorders such as skin cancers and deep fungal infections were also confused with leprosy by the general public. </p>
<p>Fear of contagion has led to <a href="https://doi.org/10.53854%2Fliim-2904-18">tremendous stigmatization and social exclusion</a>. It was such a serious concern that the Kingdom of Jerusalem had a specialized hospital to care for those suffering from leprosy.</p>
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<a href="https://images.theconversation.com/files/581102/original/file-20240311-139405-n6zvdy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Bandaged feet and legs of a person with leprosy." src="https://images.theconversation.com/files/581102/original/file-20240311-139405-n6zvdy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/581102/original/file-20240311-139405-n6zvdy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/581102/original/file-20240311-139405-n6zvdy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/581102/original/file-20240311-139405-n6zvdy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/581102/original/file-20240311-139405-n6zvdy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/581102/original/file-20240311-139405-n6zvdy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/581102/original/file-20240311-139405-n6zvdy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Leprosy has sometimes been confused with other mutilating skin disorders.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/feet-of-a-leper-royalty-free-image/157530061?phrase=leprosy&adppopup=true">visual7/E+ via Getty Images</a></span>
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<h2>How infectious is leprosy?</h2>
<p>Research shows that prolonged in-person contact via respiratory droplets is <a href="https://doi.org/10.1186/s12879-023-08627-9">the primary mode of transmission</a>, rather than through normal, everyday contact such as embracing, shaking hands or sitting near a person with leprosy. People with leprosy generally do not transmit the disease once they begin treatment. </p>
<p>Armadillos represent the only known <a href="https://doi.org/10.3201%2Feid2112.150501">zoonotic reservoir</a> of leprosy-causing bacteria that threaten humans. These small mammals are common in Central and South America and in parts of Texas, Louisiana, Missouri and other states, where they are sometimes kept as pets or farmed as meat. Eating armadillo meat is not a clear cause of leprosy, but capturing and raising armadillos, along with preparing its meat, are risk factors.</p>
<p>The transmission mechanism between zoonotic reservoirs and susceptible individuals is unknown, but it is strongly suspected that direct contact with an infected armadillo poses a significant risk of developing leprosy. However, many cases reported in the U.S. have demonstrated an <a href="https://doi.org/10.3201/eid2908.220367">absence of either zoonotic exposure or person-to-person transmission</a> outside of North America, suggesting that transmission may be happening where the infected person lives. But in many cases, the source remains an enigma.</p>
<p>Some people’s genetics might make them <a href="https://doi.org/10.1056/nejmoa0903753">more susceptible to leprosy infections</a>, or their immune systems are less capable of resisting the disease. </p>
<p>Stigma and discrimination have <a href="https://doi.org/10.53854%2Fliim-2904-18">prevented people from seeking treatment</a>, and as a result, “concealed” cases contribute to transmission. </p>
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<figcaption><span class="caption">The number of leprosy cases in the U.S. has more than doubled over the past decade, and Florida has become a hot spot for it.</span></figcaption>
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<h2>How do you recognize it?</h2>
<p>Leprosy primarily affects the skin and peripheral nervous system, causing physical deformity and desensitizing one’s ability to feel pain on affected skin. </p>
<p>It may begin with loss of sensation on whitish patches of skin or reddened skin. As the bacteria spread in the skin, they can cause the skin to thicken with or without nodules. If this occurs on a person’s face, it may rarely produce a smooth, attractive-appearing facial contour known as lepra bonita, or “pretty leprosy.” The disease can progress to causing eyebrow loss, enlarged nerves in the neck, nasal deformities and nerve damage. </p>
<p>The onset of symptoms can sometimes take <a href="https://doi.org/10.1128%2FCMR.00079-13">as long as 20 years</a> because the infectious bacteria have a lengthy incubation period and proliferate slowly in the human body. So presumably many people are infected long before they know that they are.</p>
<p>Fortunately, worldwide efforts to screen for leprosy are being enhanced thanks to organizations like the <a href="https://www.st-lazarus.us/">Order of Saint Lazarus</a>, which was originally founded in the 11th century to combat leprosy, and the <a href="https://ahri.gov.et/">Armauer Hansen Research Institute</a>, which conducts immunologic, epidemiological and translational research in Ethiopia. The nongovernmental organization <a href="https://www.bombayleprosy.org/">Bombay Leprosy Project</a> in India does the same.</p>
<h2>How treatable is it?</h2>
<p>Leprosy is not only preventable but treatable. Defying stigma and advancing early diagnosis via proactive measures are critical to the mission of controlling and eradicating it worldwide. </p>
<p>Notably, the World Health Organization and other agencies provide <a href="https://doi.org/10.25259/ijdvl_278_2023">multi-drug therapy</a> at no cost to patients. </p>
<p>In addition, vaccine technology to combat leprosy is <a href="https://doi.org/10.1016/j.vaccine.2019.12.050">in the clinical trials stage</a> and <a href="https://doi.org/10.1021/acsinfecdis.3c00371">could become available</a> in coming years. In studies involving nine-banded armadillos, this protein-based vaccine delayed or diminished leprous nerve damage and <a href="https://doi.org/10.1038/s41541-018-0050-z">kept bacteria at bay</a>. Researchers believe that the vaccine can be produced in a low-cost, highly efficient manner, with the long-term prospect of eradicating leprosy.</p>
<p>If health care professionals, biomedical researchers and lawmakers do not markedly enhance their efforts to eliminate leprosy worldwide, the disease will continue to spread and could become a far more serious problem in areas that have been largely free of leprosy for decades. </p>
<p>The World Health Organization launched a plan in 2021 for achieving <a href="https://iris.who.int/bitstream/handle/10665/340774/9789290228509-eng.pdf?sequence=1">zero leprosy</a>.</p><img src="https://counter.theconversation.com/content/221836/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Prof. Robert A. Schwartz is associated with the Order of Saint Lazarus, an international non-governmental organization committed to the fight against leprosy.</span></em></p>People often think of leprosy as a bygone disease, relevant primarily in biblical times. But in fact, it is still present in more than 120 countries, and the US is seeing an uptick in cases.Robert A. Schwartz, Professor and Head of Dermatology, Rutgers New Jersey Medical School, Rutgers UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2221272024-01-29T13:09:18Z2024-01-29T13:09:18ZNeglected tropical diseases persist in the world’s poorest places: four reads about hurdles and progress<p>It’s sobering to reflect that “neglected tropical diseases” are referred to as “neglected” because they persist in the poorest, most marginalised communities even after being wiped out in more developed parts of the world.</p>
<p>A variety of pathogens, including viruses, bacteria, parasites, fungi and toxins, cause neglected tropical diseases, which include dengue, chikungunya, leprosy, lymphatic filariasis and yaws.</p>
<p>They inflict tremendous suffering because of their disfiguring, debilitating and sometimes deadly impact. Patients often experience stigma, social exclusion and superstition. </p>
<p>The good news is that there is reason for hope as some African countries have made significant progress in eradicating these diseases. </p>
<p>We have put together some essential reads from The Conversation Africa over the past year highlighting a scourge that still affects more than <a href="https://www.who.int/news-room/questions-and-answers/item/neglected-tropical-diseases#:%7E:text=It%20is%20estimated%20that%20NTDs,often%20related%20to%20environmental%20conditions.">1 billion people </a> today. </p>
<h2>Patients’ beliefs about illness matter</h2>
<p>Would you take medication for an illness you didn’t believe you had? Or if you disagreed with healthcare workers about the cause of your condition?</p>
<p>This is the dilemma of many people who live in rural areas of Ghana where a mosquito-borne disease called lymphatic filariasis, often referred to as elephantiasis, continues to spread. Researchers found that only 18% of respondents understood lymphatic filariasis as a disease. Fewer than 7% believed it to be a disease spread by mosquitoes.</p>
<p>Instead, people held a range of alternative beliefs attributing the condition to spiritual causes (curses, witchcraft, evil spirits), cold or rainy weather, and other illnesses.</p>
<p>The team of experts, that carried out the research, suggest that understanding patients’ belief systems would help healthcare workers treat patients more effectively. </p>
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Read more:
<a href="https://theconversation.com/patients-beliefs-about-illness-matter-the-case-of-elephantiasis-in-rural-ghana-216838">Patients' beliefs about illness matter: the case of elephantiasis in rural Ghana</a>
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<h2>100 million Nigerians are at risk</h2>
<p>A quarter of the people affected by neglected tropical diseases in Africa live in Nigeria. An estimated 100 million Nigerians are at risk for at least one of these diseases and there are several million cases of people being infected with more than one of them.</p>
<p>There has been progress, writes Uwem Friday Ekpo. By January 2023 the country had eradicated Guinea worm disease and two states had eliminated onchocerciasis. </p>
<p>One of the interventions was door-to-door visits by volunteers to administer medicines. Teachers also played a similar role when medicines were distributed in schools. </p>
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Read more:
<a href="https://theconversation.com/100-million-nigerians-are-at-risk-of-neglected-tropical-diseases-what-the-country-is-doing-about-it-198320">100 million Nigerians are at risk of neglected tropical diseases: what the country is doing about it</a>
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<h2>Leprosy, scabies and yaws: Togo’s neglected skin diseases</h2>
<p>Skin conditions caused by some bacteria, viruses, mosquitoes or mites are common neglected tropical diseases. </p>
<p>Research in schools and rural areas in Togo, west Africa, found a large number of these infections including scabies, leprosy, yaws and Buruli ulcer.</p>
<p>These are stigmatised and can be difficult to diagnose. There are typically few, if any, dermatologists in areas where they are common. Children with these diseases often refuse to go to school. </p>
<p>Michael Head, Bayaki Saka and Palokinam Pitche suggest authorities make the treatment of these diseases free of charge. Health promotion and education are also critical.</p>
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Read more:
<a href="https://theconversation.com/leprosy-scabies-and-yaws-togos-neglected-tropical-skin-diseases-need-attention-201301">Leprosy, scabies and yaws - Togo's neglected tropical skin diseases need attention</a>
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<h2>Reasons for hope</h2>
<p>Togo did have reason to celebrate though. In 2022 it became the first country in the world to have eliminated four neglected tropical diseases. The country stamped out Guinea worm disease in 2011, lymphatic filariasis in 2017, sleeping sickness in 2020 and trachoma in 2022.</p>
<p>It achieved its milestone through a combination of measures. These included door-to-door mass drug administration, training of healthcare staff, sustained financing and strong political support.</p>
<p>Other African countries also made significant progress in tackling neglected tropical diseases in 2022. Benin, Rwanda and Uganda managed to eliminate sleeping sickness. Malawi eliminated trachoma and the Democratic Republic of Congo eliminated Guinea worm disease.</p>
<p>But the global health community and African governments cannot rest on their laurels. There is still a long way to go, writes Monique Wasunna. </p>
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Read more:
<a href="https://theconversation.com/eliminating-neglected-diseases-in-africa-there-are-good-reasons-for-hope-198543">Eliminating neglected diseases in Africa: there are good reasons for hope</a>
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<img src="https://counter.theconversation.com/content/222127/count.gif" alt="The Conversation" width="1" height="1" />
Neglected tropical diseases are often associated with social exclusion as well as physical suffering. One billion people around the world suffer from these diseases.Nadine Dreyer, Health & Medicine EditorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1983202023-01-27T12:00:19Z2023-01-27T12:00:19Z100 million Nigerians are at risk of neglected tropical diseases: what the country is doing about it<figure><img src="https://images.theconversation.com/files/506334/original/file-20230125-3412-a5widk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A nurse gives gives medicine, Ivermectin, against onchocerciasis or river blindness.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/christophe-koffi-a-nurse-mamadou-kone-gives-medecine-news-photo/83038610?phrase=onchocerciasis%20in&adppopup=true">Issouf Sanogo/AFP via Getty Images </a></span></figcaption></figure><p>Neglected tropical diseases are a group of communicable diseases found in tropical and subtropical regions of the world. They are classified as “neglected” because they have received little or no attention in terms of prevention and control for several decades. The World Health Organization guides the way they are identified and managed. </p>
<p>These <a href="https://www.who.int/health-topics/neglected-tropical-diseases#tab=tab_1">20 conditions</a> mostly affect impoverished communities, women and children. Most people affected by them live in rural areas where houses are overcrowded, and basic infrastructure such as water and toilet facilities are lacking. <a href="https://unitingtocombatntds.org/ntds/">More than one billion people</a> are estimated to be affected globally.</p>
<p>The neglected tropical diseases include <a href="https://www.who.int/news-room/fact-sheets/detail/onchocerciasis">onchocerciasis</a>, <a href="https://www.who.int/news-room/fact-sheets/detail/schistosomiasis">schistosomiasis</a>, <a href="https://www.who.int/news-room/fact-sheets/detail/lymphatic-filariasis">lymphatic filariasis</a>, <a href="https://www.who.int/news-room/fact-sheets/detail/soil-transmitted-helminth-infections">soil-transmitted helminth infections</a> and <a href="https://www.who.int/news-room/fact-sheets/detail/trachoma#:%7E:text=Trachoma%20is%20a%20disease%20of,Blindness%20from%20trachoma%20is%20irreversible.">trachoma</a>. Also among them are <a href="https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue">dengue fever</a>, <a href="https://www.healthline.com/health/leptospirosis">leptospirosis</a>, <a href="https://www.who.int/news-room/fact-sheets/detail/trypanosomiasis-human-african-(sleeping-sickness)">trypanosomiasis</a>, <a href="https://www.who.int/news-room/fact-sheets/detail/leishmaniasis">leishmaniasis</a>, <a href="https://www.who.int/news-room/fact-sheets/detail/buruli-ulcer-(mycobacterium-ulcerans-infection)">Buruli ulcer</a>, <a href="https://www.who.int/news-room/fact-sheets/detail/leprosy">leprosy</a> and snake-bite envenoming. </p>
<p>More than <a href="https://end.org/ntds-in-focus/#:%7E:text=Neglected%20Tropical%20Diseases%20Statistics,blindness%20results%20in%20social%20isolation.">170,000</a> people die of these diseases annually – fewer than <a href="https://reliefweb.int/report/world/world-malaria-report-2021">malaria with 627,000 deaths in 2020</a>. But the diseases can cause disfigurement, stigmatisation, malnutrition and cognition problems, leading to a range of social, economic and psychological burdens for those affected. </p>
<p>Nigeria carries a particularly heavy burden. A quarter of the people affected by neglected tropical diseases in Africa <a href="https://www.sightsavers.org/blogs/2019/03/research-ntds-nigeria/">live in Nigeria</a>. An estimated <a href="https://www.sightsavers.org/blogs/2019/03/research-ntds-nigeria/">100 million</a> people in the country are at risk for at least one of the diseases and there are several million cases of people being infected with more than one of them.<br>
As an <a href="https://www.researchgate.net/profile/Uwem-Ekpo">epidemiologist</a> who has studied some of these diseases for 21 years and provided technical support for control activities, I can say that Nigeria has made progress in controlling them. The country has <a href="https://www.afro.who.int/news/down-zero-nigeria-stops-guinea-worm-disease-its-tracks">eradicated Guinea-worm disease</a> and two states have eliminated onchocerciasis. But it can still do more. </p>
<p>Other diseases are still endemic in Nigeria. There is a National Neglected Tropical Diseases steering committee overseeing control efforts. There are also control units at the federal, state and local government levels. Local and international donors are helping as partners. Progress has been made in mapping of the diseases, development of master plans and the delivery of intervention.</p>
<h2>Global efforts</h2>
<p>The WHO puts efforts to control the diseases into two categories: prevention and management. </p>
<p>Preventive control is about administration of efficacious, safe, and inexpensive medicines. The diseases that can be prevented this way include onchocerciasis, schistosomiasis, lymphatic filariasis, soil-transmitted helminths and trachoma. They are <a href="https://www.sciencedirect.com/science/article/pii/S1201971215002660">the most common in sub-Saharan Africa</a>. </p>
<p>Diseases that lack appropriate tools for large scale use are managed case by case. </p>
<p>In 2012, pharmaceutical companies, donors, endemic countries and NGOs <a href="https://globalhealthprogress.org/collaboration/the-london-declaration-on-ntds-2/#:%7E:text=On%2030%20January%202012%2C%20pharmaceutical,of%20over%20a%20billion%20people.">signed the London Declaration on Neglected Tropical Diseases</a>. They committed to control, eliminate or eradicate 10 priority diseases by 2020.</p>
<p><a href="https://www.who.int/news/item/27-05-2021-world-health-assembly-adopts-decision-to-recognize-30-january-as-world-ntd-day#:%7E:text=Today%2C%20delegates%20participating%20in%20the,World%20NTD%20Day%20in%202020.">In 2020</a>, World Neglected Tropical Diseases Day was declared, to be marked on 30 January every year.</p>
<p>The various global initiatives have built capacity for African scientists through research grants, and created awareness and funding partnerships to meet the <a href="https://www.who.int/publications/i/item/9789240010352">WHO 2030 elimination goals</a> in Africa.</p>
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Read more:
<a href="https://theconversation.com/how-the-gambia-beat-trachoma-an-infection-that-causes-blindness-160716">How The Gambia beat trachoma, an infection that causes blindness</a>
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<h2>Nigeria</h2>
<p>Nigeria began concerted efforts to combat human and animal trypanosomiasis (sleeping sickness and nagana) <a href="https://www.asti.cgiar.org/nigeria/directory/nigerian-institute-trypanosomiasis-research-nitr">in 1947</a> with the establishment of Nigerian Institute for Trypanosomiasis Research, Kaduna. Large scale human onchocerciasis (river blindness) control efforts <a href="https://ispub.com/IJPD/4/1/9548">started in 1988</a>. When drug efficacy evidence become available, the National Lymphatic Filariasis Elimination Programme was <a href="https://www.health.gov.ng/doc/NLFEP_Assessment-Guidelines_August2019_07012020.pdf">established in 1997</a>. </p>
<p>Support for the procurement, delivery and distribution of medicines increased in the 1990s through donor programmes. Control units were established at the Federal Ministry of Health, and all 36 states were given the responsibility to implement control activities using recommended medicines. </p>
<p>To reach the marginalised populations who bear the greatest burden of these diseases, volunteers visit from door to door to administer medicines to people in their community. Teachers also played similar role where the drug distribution is school-based. </p>
<p>These interventions are supported through the national budget, bilateral aid and direct support from development partners. Medicines are donated by pharmaceutical companies, and deliveries are coordinated by the WHO. </p>
<p><a href="https://espen.afro.who.int/countries/nigeria">The treatment data</a> for human onchocerciasis and lymphatic filariasis (elephantiasis) from 2014 to 2021 showed progress in the number of people treated and achieving WHO treatment coverage of 65%. However, for schistosomiasis (bilharzia) and soil transmitted helminthiasis (intestinal worms), Nigeria has not been able meet the recommended coverage of 75% set by WHO. </p>
<p>This shows that the control and elimination of these diseases are in progress. </p>
<p>The lowest coverage was recorded during the COVID pandemic 2020 and 2021. </p>
<p>Two states (Plateau and Nasarawa) have interrupted the transmission of onchocerciasis. A number of local governments are near elimination stage – 61 in 2021. This shows that the disease is under control. </p>
<p>Lymphatic filariasis is also on a downward trend, but only 37 local government areas are nearing elimination. The disease <a href="https://www.afro.who.int/news/who-sustains-lymphatic-filariasis-treatments-over-500-local-government-areas-across-nigeria">is found in 520 local governments</a> out of 774 in Nigeria.</p>
<p>For schistosomiasis, treatment coverage has been below the WHO target. This is largely due to inadequate drug supply and the challenges of treating children in and outside the school system. The WHO introduced <a href="https://www.who.int/publications/i/item/9789240041608">new guidelines on control and elimination </a> in 2022. The road map targets the elimination of schistosomiasis as a public health problem, globally. The new guidelines also recommended the implementation of other interventions such as provision of water, sanitation and hygiene education (WASH), behavioural health education and snail control to break the transmission of schistosomiasis in affected communities. </p>
<p>For soil transmitted helminthiasis, 117 local government areas have achieved more than 75% treatment coverage out of the 147 targeted for treatment. </p>
<p>Nigeria has taken <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7392186/">massive strides towards reducing trachoma prevalence</a>.</p>
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<a href="https://theconversation.com/how-covid-has-affected-the-control-of-neglected-tropical-diseases-178324">How COVID has affected the control of neglected tropical diseases</a>
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<h2>The way forward</h2>
<p>Preventive control of neglected tropical diseases relies on mass administration of drugs. This requires substantial financial and human resources. More importantly, effective communal participation is vital. But there is <a href="https://www.researchgate.net/publication/266327287_Public_Awareness_and_Knowledge_of_Neglected_Tropical_Diseases_NTDs_Control_Activities_in_Abuja_Nigeria_Editor">low public awareness about these diseases</a> and the efforts being made to control them. </p>
<p>The shortage of medicines, poor financial support and material logistics for treatment campaigns are not helping control and elimination efforts. Additional challenges are poor political will, lack of NGO partner in some states, and apathy among drug distributors and health workers due to lack of incentives. These challenges got worse during the pandemic. </p>
<p>Government and stakeholders at all levels should commit to control activities through increased funding. There should also be sensitisation of citizens through advocacy to support control activities in their communities. It is important that Nigeria should enact legislation to drive and scale up control activities. Otherwise the country would be left behind when these diseases have been controlled or eliminated in the rest of sub-Saharan Africa by 2030.</p><img src="https://counter.theconversation.com/content/198320/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Uwem Friday Ekpo does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>While Nigeria has made progress in controlling some neglected tropical diseases, it should do more as it carries a heavy burden of these diseases.Uwem Friday Ekpo, Professor of Parasitology and Epidemiology, Federal University of Agriculture, AbeokutaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1985432023-01-26T13:34:59Z2023-01-26T13:34:59ZEliminating neglected diseases in Africa: there are good reasons for hope<figure><img src="https://images.theconversation.com/files/506411/original/file-20230125-16-drokh2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Head nurse Luke Kanyang'areng' with a visceral leishmaniasis patient at the Kacheliba Sub-County Hospital in Kenya.</span> <span class="attribution"><span class="source">Rowan Pybus-DNDi</span></span></figcaption></figure><p>Togo had reason to celebrate in 2022 when it became the first country in the world <a href="https://www.theguardian.com/global-development/2022/aug/25/togo-achieves-major-feat-of-eradicating-four-neglected-tropical-diseases">to eliminate four neglected tropical diseases</a>. The west African nation stamped out <a href="https://www.cdc.gov/parasites/guineaworm/index.html">Guinea worm disease</a> in 2011, <a href="https://www.cdc.gov/parasites/lymphaticfilariasis/index.html">lymphatic filariasis</a> in 2017, <a href="https://www.cdc.gov/parasites/sleepingsickness/">sleeping sickness</a> in 2020, and <a href="https://www.cdc.gov/hygiene/disease/trachoma.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fhealthywater%2Fhygiene%2Fdisease%2Ftrachoma.html">trachoma</a> last year. </p>
<p>These diseases are transmitted in various ways. Guinea worm disease, for instance, is water-borne while sleeping sickness is transmitted by the tsetse fly. </p>
<p>They are just a few among a host of neglected tropical diseases, which mostly affect impoverished communities and that are exacerbated by instability, climate change, and poor living conditions. Every year, <a href="https://www.who.int/news/item/16-07-2020-neglected-tropical-diseases-treating-more-than-one-billion-people-for-the-fifth-consecutive-year">1.7 billion</a> people are affected by these diseases. They cause immense suffering, stigma, disability – and sometimes death. </p>
<p>Togo achieved its milestone through a combination of measures. These included door-to-door mass drug administration, training of healthcare staff, sustained financing, and strong political support. </p>
<p>Other African countries also made significant progress in tackling neglected tropical diseases in 2022. Benin, Rwanda and Uganda managed to <a href="https://www.who.int/news/item/24-05-2022-benin--uganda-and-rwanda-eliminate-human-african-trypanosomiasis-as-a-public-health-problem">eliminate sleeping sickness</a>. Malawi <a href="https://www.who.int/news/item/21-09-2022-malawi-eliminates-trachoma-as-a-public-health-problem">eliminated trachoma</a> and the Democratic Republic of Congo (DRC) <a href="https://www.who.int/news/item/15-12-2022-the-democratic-republic-of-the-congo-certified-free-of-dracunculiasis-transmission-by-who">eliminated Guinea worm disease</a>. </p>
<p>On another continent, in India, Prime Minister Narendra Modi applauded his country’s success in eliminating smallpox, polio and Guinea worm disease, while expressing confidence it could “<a href="https://www.freepressjournal.in/india/mann-ki-baat-pm-modi-talks-about-eradicating-kala-azar-what-is-it-what-are-its-symptoms">soon</a>” eliminate another neglected tropical disease, visceral leishmaniasis.</p>
<p>All of this means there’s plenty of reason to celebrate. But the global health community cannot rest on its laurels. These diseases are still present in some areas. </p>
<p>The insects that transmit many of these diseases don’t respect borders – so no one is safe until everyone is. The COVID-19 pandemic gravely disrupted control programmes, <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(22)00360-6/fulltext">delaying the achievement of elimination goals by years</a> for some diseases. Some countries are also struggling to tackle neglected tropical diseases because of instability and conflicts that hinder control efforts, or because they have large remote regions that are difficult to reach.</p>
<p>Adequate funding is needed to support drug distribution, training of healthcare staff, and raising awareness. Funding for research and development is crucial, too, so that the promising innovations emerging from African laboratories and clinical trial sites can reach doctors and patients.</p>
<h2>Improved treatments</h2>
<p>One of the challenges in tackling many neglected tropical diseases is the absence of adequate treatments. Existing medicines are often not effective enough or are difficult to administer, such as regular injections that require hospitalisation. Some treatments are very painful. Others are downright toxic. For some diseases, such as a fungal infection called <a href="https://dndi.org/diseases/mycetoma/facts/">mycetoma</a>, which is endemic in Sudan, there are no effective treatments at all – amputation is often the only option.</p>
<p>Because these diseases affect the poorest communities and there is little profit to be made from developing new drugs, they have been historically ignored by traditional pharmaceutical research.</p>
<p>But the abundance of good news last year has given me hope. 2022 was an incredible year for visceral leishmaniasis, which is endemic in eastern Africa and is <a href="https://theconversation.com/innovation-and-research-are-key-to-killing-off-neglected-tropical-diseases-in-africa-153914">my field of expertise</a> as a physician and specialist in infectious diseases and tropical medicine.</p>
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Read more:
<a href="https://theconversation.com/innovation-and-research-are-key-to-killing-off-neglected-tropical-diseases-in-africa-153914">Innovation -- and research -- are key to killing off neglected tropical diseases in Africa</a>
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<p>The disease is fatal if left untreated. It’s the deadliest <a href="https://www.reuters.com/article/global-health-disease-idAFL3N2O9075">parasitic killer</a> after malaria. Those infected with visceral leishmaniasis suffer from fever, weight loss and intense fatigue. Many are unable to work, which means a loss of income for their families.</p>
<p>But in September 2022, a <a href="https://www.nature.com/articles/d44148-022-00138-0">shorter, more effective new treatment</a> was announced. Developed with several partners, including Médecins Sans Frontières, this treatment partially removes the need for daily injections. </p>
<p>In June, the World Health Organization also <a href="https://www.npr.org/sections/goatsandsoda/2022/07/07/1110146123/a-nasty-disease-is-even-nastier-for-patietnts-with-hiv-now-theres-encouraging-ne?ft=nprml&f=">recommended</a> an improved treatment specifically for people who are co-infected with HIV and visceral leishmaniasis. This gives hope for the thousands of patients – often young seasonal migrant workers – who respond poorly to standard treatment.</p>
<p>Promising results for a new, one-dose drug for sleeping sickness were also <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00660-0/fulltext">announced</a> last year following clinical studies conducted in the DRC and Guinea by Congolese and Guinean researchers. This new medicine would be a significant improvement over existing drugs and could open the door to sustainably eliminating the disease. This is a remarkable achievement. I still remember when the only drug available to my fellow doctors in the DRC was an arsenic derivative so toxic it <a href="https://www.doctorswithoutborders.org/latest/fire-veins-still-injecting-arsenic-derivatives-treat-african-sleeping-sickness">killed 5%</a> of their patients.</p>
<h2>Collaboration and partnerships</h2>
<p>However, research and development efforts alone are not enough. Collaboration and partnerships are key. These are not just buzzwords: past successes in tackling neglected tropical diseases have been rooted in close-knit partnerships between national health authorities, international donors, medical research institutes, universities and industry.</p>
<p>The new treatments I mentioned above were all developed thanks to such coalitions. I am the director of the Eastern Africa office of a global non-profit medical research organisation called <a href="https://dndi.org/">Drugs for Neglected Diseases Initiative</a>, which took an active role in all these research and development collaborations.</p>
<p>The good news is that new partnerships keep being formed. In 2022, we established LeishAccess, a regional collaboration in Eastern Africa working to <a href="https://news.scienceafrica.co.ke/new-program-to-scale-up-access-to-leishmaniasis-treatments-launched/">promote access to visceral leishmaniasis treatments</a> and remove the obstacles that still prevent half of patients from accessing the life-saving drugs they need.</p>
<p>All these advances give me hope. These extraordinary efforts will eventually pay off. I am convinced that, in a not-so-distant future, people will stop dying from leishmaniasis, and will be safely cured thanks to simple oral drugs.</p>
<p>Many gaps remain, with millions of people still suffering from diseases that could be cured. And neglected tropical diseases that are slowly disappearing can suddenly come back with a vengeance, fuelled by conflicts, economic crises, increased poverty, or climate change.</p>
<p>But if sustained investment is coupled with African political leadership and scientific excellence, there’s good reason to hope for the elimination of neglected tropical diseases on the continent.</p><img src="https://counter.theconversation.com/content/198543/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Monique Wasunna is the director of the Drugs for Neglected Diseases initiative Africa Regional Office.</span></em></p>Every year, 1.7 billion people, most in the world’s poorest areas, are affected by NTDs. The diseases cause suffering, stigma, disability and sometimes death.Monique Wasunna, Researcher, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1921062022-10-12T14:08:31Z2022-10-12T14:08:31ZMozambique had no data about snakebites. Our new study filled the gap – and the results are scary<figure><img src="https://images.theconversation.com/files/488755/original/file-20221007-7785-4xd2be.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Stiletto Snake is one of the species found in Mozambique. </span> <span class="attribution"><span class="source">extinctorshy.org - Ali Puruleia</span></span></figcaption></figure><p>Every year between 20,000 and 32,000 people in sub-Saharan Africa die after being <a href="https://www.sciencedirect.com/topics/pharmacology-toxicology-and-pharmaceutical-science/snakebite">bitten by snakes</a>. That’s more than five times the number of deaths caused by <a href="https://www.nationalgeographic.com/animals/article/hippos-flooding-fishing-covid-collide-kenya">hippos</a>, <a href="http://www.crocodile-attack.info/">crocodiles</a>, <a href="https://www.statista.com/statistics/448169/deadliest-creatures-in-the-world-by-number-of-human-deaths/">elephants, lions and buffalo</a> combined. </p>
<p>At least, that’s what the available data suggests. But, the World Health Organization (WHO) <a href="https://apps.who.int/iris/bitstream/handle/10665/324838/9789241515641-eng.pdf#page=17">acknowledges</a>, that statistics – as well as figures related to non-fatal injury and disability caused by snakebites – are incomplete. Not all snakebite victims are treated in hospitals, especially in poorer countries and communities. Some may be treated by traditional doctors. Others may die before receiving any treatment.</p>
<p>But without accurate data, it is difficult to see how the WHO will meet its <a href="https://apps.who.int/iris/bitstream/handle/10665/324838/9789241515641-eng.pdf">global target</a> of reducing death and disability from snakebites by 50% by 2030. Without it, it’s difficult to prioritise which countries or regions require financial resources or antivenom, for instance.</p>
<p>We wanted to find a different way to quantify snakebites. So my colleagues and I from Mozambique’s Lúrio University embarked on <a href="https://www.sciencedirect.com/science/article/pii/S004101012200277X">a household survey</a> across nine rural villages in Cabo Delgado Northern Mozambique. Before this, the only existing snakebite data for Mozambique was extrapolated from incidents in other countries in sub-Saharan Africa. This <a href="https://www.sciencedirect.com/science/article/abs/pii/S0041010118311802">suggested</a> there were 6996 snakebite cases and 319 deaths annually in Mozambique.</p>
<p>Our results offer a very different and extremely worrying picture. From our data we extrapolated snakebite figures for the entire area and for Mozambique as a whole. Despite being an underestimation (since we favoured a conservative approach) they increase snakebite incidence levels ten-fold and the number of deaths by 30-fold. </p>
<p>Urgent and widespread surveys are needed to further assess the full extent of snakebites in sub-Saharan Africa, explore regional patterns and develop mitigation plans. Obtaining this sort of data is critical: the WHO has placed snakebite in <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31751-8/fulltext">category A</a> (the most severe or urgent) of neglected tropical diseases. Its 2030 target underscores that this is a priority area. But how can this metric be checked without accurate data?</p>
<h2>Gathering data</h2>
<p>We gathered data from 1037 households. We asked about snakebite incidents in people’s own homes and among their neighbours, as well as details about the species of snake, the symptoms, and what sort of treatment the victim received, if any. </p>
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<a href="https://theconversation.com/snakebites-still-exact-a-high-toll-in-africa-a-shortage-of-antivenoms-is-to-blame-80982">Snakebites still exact a high toll in Africa. A shortage of antivenoms is to blame</a>
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<p>There were 296 reported snakebites and most (60%) were treated exclusively by traditional doctors; 15% went to hospitals for treatment and 25% died before reaching any doctor. </p>
<p>Using a conservative estimation where we assume our results to be extrapolatable for the whole of rural Mozambique, but considering snakebites in urban areas to be inexistent, we propose that every year in Cabo Delgado, at least 6124 people are victims of snakebites. Of these at least 791 result in deaths. </p>
<p>In Mozambique, we extrapolated that every year at least 69,261 people are victims of snakebite; at least 8950 result in death, meaning that one in eight snakebites is fatal. <a href="https://www.statista.com/statistics/1268021/main-causes-of-deaths-in-mozambique/">For comparison</a>, 37,000 people die in Mozambique (which is home to more than 30 million people) each year because of respiratory infections and tuberculosis while 21,000 die from malaria.</p>
<p><a href="https://www.resakss.org/sites/default/files/pdfs/MozSAKSS_ATOR_2010.pdf">Most</a> (68%) of the population live in rural areas and practice subsistence farming for a living. This means that millions of people are exposed to snakebites. The country is home to at least <a href="https://link.springer.com/article/10.1186/s13002-021-00493-6">14 snake species of medical importance</a> – those whose bites can kill or lead to limb amputation. This is a fairly standard number of such snakes for the continent’s less tropical regions.</p>
<p>The number of medically important snakes in the country, the percentage of people living in rural areas, and the total absence of snakebite incidence data, make Mozambique a good place to focus on when trying to quantify and model snakebite data.</p>
<h2>Who gets bitten and where</h2>
<p>Some of our other key findings included:</p>
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<li><p>Most bites occurred on farms and during the rainy season (December to April).</p></li>
<li><p>The type of snake was important when people were choosing between hospitals or traditional doctors. Those bitten by dangerous species such as the <a href="https://www.africansnakebiteinstitute.com/snake/puff-adder/">Puff Adder</a> were usually taken to hospitals. Bites from less dangerous species like the <a href="https://www.africansnakebiteinstitute.com/articles/beware-of-the-stiletto-snake/">Stiletto Snake</a> were taken to traditional doctors. </p></li>
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<a href="https://theconversation.com/finally-snakebite-is-getting-more-attention-as-a-tropical-health-issue-131016">Finally, snakebite is getting more attention as a tropical health issue</a>
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<p>One exception was made for victims of <a href="https://www.sanbi.org/animal-of-the-week/black-mamba/">Black Mambas</a>. This deadly snake has extremely fast-acting venom: its bite can kill in less than an hour. In the communities we surveyed, Black Mamba victims were usually taken to traditional doctors close to home, to avoid long trips to hospitals up to 20km away and queues at the facilities. </p>
<h2>Figures may be higher</h2>
<p>It is possible that our figures are too low. That’s because we took a conservative approach when extrapolating data – and because we assumed that every interviewee had 100% recall, as well as assuming a 0% snakebite incidence in urban areas, which make up 30% of the country.</p>
<p>So, the figures for snakebite incidence are very likely still an underestimation of the true incidence in both Cabo Delgado and Mozambique more broadly. </p>
<p>Local universities should consider using our approach to engage with communities and retrieve household data. This will help researchers and health authorities to assess the full extent of snakebites in sub-Saharan Africa, explore regional patterns and develop mitigation plans.</p>
<p>Such mitigation might include training both traditional doctors and hospital staff in snakebite treatment; public education campaigns to encourage people to use hospitals for treating snakebites; and making antivenom widely available. It may also be useful to generate local literature to guide snake identification and share first-aid measures.</p><img src="https://counter.theconversation.com/content/192106/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harith Omar Morgadinho Farooq does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Even by conservative estimates, Mozambique’s snakebite figures are far higher than previously thought.Harith Omar Morgadinho Farooq, Post-doc, University of CopenhagenLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1833662022-06-13T13:29:32Z2022-06-13T13:29:32ZMolecular research could help Nigeria solve a host of health problems<figure><img src="https://images.theconversation.com/files/464752/original/file-20220523-42302-ho3i3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Molecular research like that conducted at the African Centre of Excellence for Genomics of Infectious Diseases in Nigeria is key to medical breakthroughs.</span> <span class="attribution"><span class="source">PIUS UTOMI EKPEI/AFP via Getty Images</span></span></figcaption></figure><p>Our world and everything in it is made up of innumerable tiny molecules. These molecules are the smallest units of chemical compounds or living things. Viruses, bacteria, parasites, plants, animals, humans: each organism is underpinned by molecules. Studying them allows scientists to understand the basic principles and interactions that govern all forms of life. </p>
<p>Shifts at such basic levels change the way an organism looks or functions. That’s critical in understanding diseases, for one thing. During the COVID-19 pandemic, molecular research enabled scientists to quickly understand how the new coronavirus behaved and how to prevent infection. That, in turn, drove <a href="https://www.scienceboard.net/index.aspx?sec=rca&sub=ASGC_2022&pag=dis&ItemID=4298">vaccine development</a>.</p>
<p>Molecular research could also, in future, make it possible to personalise medicine – basing treatment on a patient’s DNA. And it may be key to progress in the treatment of diseases such as sickle cell anaemia, diabetes and cancer.</p>
<p>There’s a problem, though: molecular research is expensive. It requires specialised equipment and chemicals, which is costly.</p>
<p>In Nigeria, where I conduct molecular research – and in many other African countries – there is very little state funding for research and development. Nigeria’s <a href="https://tetfundserver.com/">TETFund</a>, the government agency responsible for all higher education funding, has very <a href="https://www.premiumtimesng.com/news/top-news/399432-buhari-approves-n7-5-billion-for-research-grants.html">limited resources</a>. Molecular research is often neglected in funding decisions in favour of other forms of research that could provide immediate solutions to pressing societal needs, such as immediate control measures for disease outbreaks.</p>
<p>As I argued in a recent <a href="https://www.frontiersin.org/articles/10.3389/frma.2021.788673/full">journal article</a>, though, molecular research can help address some of Nigeria’s health needs. Nigeria has a rich <a href="https://medcraveonline.com/IJAWB/factors-affecting-the-population-trend-of-biodiversity-in-the-niger-delta-region-of-nigeria.html">biodiversity</a> of humans, animals and plants whose molecular compositions may hold clues to future advancements in medical science. The country also bears a huge <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02722-7/fulltext">burden</a> of infectious disease. Microorganisms that cause <a href="https://www.globalcitizen.org/en/content/nigeria-neglected-tropical-diseases-explainer/">diseases</a> abound in the tropical climate of Nigeria. </p>
<p>Investment in research into the molecular characteristics of these microorganisms would go a long way in disease control and management both locally and globally. </p>
<h2>Untapped contributions</h2>
<p>It’s worth noting what Nigeria’s molecular research scientists have already been able to achieve without good resources. </p>
<p>They were at the forefront of sequencing the SARS-CoV-2 genome within days of the first infection being recorded on Nigerian soil. This work allowed them to publish the <a href="https://virological.org/t/first-african-sars-cov-2-genome-sequence-from-nigerian-covid-19-case/421">first SARS-CoV-2 sequence data</a> on the African continent. This was made possible by many years of international and local funding to build capacity at the African Centre of Excellence for the Genomics of Infectious Disease and the Nigerian Institute of Medical Research.</p>
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Read more:
<a href="https://theconversation.com/nigerian-scientists-have-identified-seven-lineages-of-sars-cov-2-why-it-matters-144234">Nigerian scientists have identified seven lineages of SARS-CoV-2: why it matters</a>
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<p>Imagine how much more could be done and how Nigeria could contribute to global health solutions if its numerous excellent scientists were properly equipped with adequate facilities. </p>
<p>South Africa has demonstrated this dedicated research support via its <a href="https://www.nrf.ac.za/">National Research Foundation</a>. Huge funds have been invested in research for the control of HIV and AIDS and, more recently, COVID-19.</p>
<p>At present, most Nigerian molecular research scientists do not have the specialised research equipment they need. This is because of cost and limited availability. Most of this equipment, and the chemical reagents needed for this work, is imported. There are a few specialised reference molecular laboratories in the country, but not nearly enough to serve the needs of this nation of more than <a href="https://data.worldbank.org/indicator/SP.POP.TOTL?locations=NG">200 million people</a>. </p>
<p>Universities, which are the ideal spaces for such research facilities, don’t offer adequate institutional support for procuring molecular research equipment and reagents. </p>
<p>Yet there are many diseases peculiar to the country and region, for which new treatments could be easily developed with the aid of molecular research. They include genetic diseases like <a href="https://www.afro.who.int/health-topics/sickle-cell-disease">sickle cell</a>, noncommunicable diseases like <a href="https://diabetesatlas.org/data/en/country/145/ng.html">diabetes</a>, and infectious diseases like <a href="https://theconversation.com/africa/topics/malaria-762">malaria</a> and <a href="https://www.who.int/health-topics/neglected-tropical-diseases#tab=tab_1">neglected tropical diseases</a> (among them river blindness and sleeping sickness or African trypanosomiasis). </p>
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<a href="https://theconversation.com/new-finding-offers-breakthrough-in-beating-african-sleeping-sickness-65569">New finding offers breakthrough in beating African sleeping sickness</a>
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<p>Nigeria – and the African continent – cannot continue to wait for western researchers to find solutions to these peculiar health challenges. </p>
<h2>Concerted effort</h2>
<p>Nigeria has the opportunity to contribute an enormous amount of knowledge to molecular research. For this to happen, a concerted effort is required by the government, institutions, local and international funding bodies, and molecular researchers themselves. </p>
<p>COVID-19 has taught us that a health problem in one place could threaten global health. Therefore all hands should be on deck to tackle health challenges wherever they occur. </p>
<p>There is a strong need for national and international funding bodies to increase funding allocations to improve molecular research capacity in Africa. Also, universities and research institutions should provide an enabling environment by providing easy access to the equipment and facilities that researchers need. Researchers will thus be encouraged to find solutions to health challenges and train more scientists.</p><img src="https://counter.theconversation.com/content/183366/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chinwe Uzoma Chukwudi receives funding from National Institutes of Health, Bill and Melinda Gates Foundation and African Academy of Sciences. </span></em></p>Molecular research is expensive, but worth it because of the burden of disease that it could relieve.Chinwe Uzoma Chukwudi, Senior lecturer in Molecular Pathology and Microbial Genetics, University of NigeriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1783242022-03-10T14:58:43Z2022-03-10T14:58:43ZHow COVID has affected the control of neglected tropical diseases<figure><img src="https://images.theconversation.com/files/450893/original/file-20220309-18-1o0cwh.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A case of advanced liver pathology (hepatomegaly) due to schistosomiasis in a 5-year-old. </span> <span class="attribution"><span class="source">Prof Takafira Mduluza</span></span></figcaption></figure><p><a href="https://www.who.int/publications/i/item/who-wer9638-461-468">Neglected tropical diseases</a> is an umbrella term used to describe a group of 20 infectious diseases. These diseases affect over 1.7 billion people. They can disable, debilitate and even kill. The world’s most vulnerable and poorest are most affected. In the past, the diseases in this group have been overlooked internationally and poorly funded domestically: hence the “neglected” in the name. Some common neglected tropical diseases are <a href="https://www.cdc.gov/buruli-ulcer/index.html">Buruli Ulcer</a>, <a href="https://www.cdc.gov/dengue/">Dengue Fever</a> and <a href="https://www.cdc.gov/leprosy/">Hansen’s disease (also known as leprosy)</a>.</p>
<p>There are already <a href="https://www.who.int/data/gho/data/themes/neglected-tropical-diseases">tools to prevent and treat</a> these diseases. They include drugs, vector control, veterinary public health interventions and provision of safe water and toilets. </p>
<p>In the past 10 years there have been significant global efforts to control neglected tropical diseases. In 2012, pharmaceutical companies, donors, endemic countries and non government organisations came together to sign the <a href="https://unitingtocombatntds.org/resource-hub/who-resources/london-declaration-neglected-tropical-diseases/">London Declaration on Neglected Tropical Diseases</a>. Together, they committed to control, eliminate or eradicate ten of these diseases by 2020 and improve the lives of over a billion people. Support from the signatories ranged from <a href="https://accesstomedicinefoundation.org/access-to-medicine-index/best-practices/medicine-donations-for-neglected-tropical-diseases">donation of the essential medicines</a> to financing the <a href="https://schistosomiasiscontrolinitiative.org/about/how-money-is-spent">delivery and distribution</a> of the drugs, research, and funding for sanitation and safe water. These concerted global efforts have yielded successes and are grounds for optimism.</p>
<p>To date, <a href="https://www.eisai.com/news/2022/news202209.html#:%7E:text=Forty%2Dthree%20countries%20have%20eliminated,people%20remain%20threatened%20by%20NTDs.">600 million</a> people no longer require treatment for neglected tropical diseases. Cases of some of these diseases, such as leprosy, sleeping sickness and Guinea worm disease, are at an all-time low. Forty-four <a href="https://www.eisai.com/news/2022/news202209.html#:%7E:text=Forty%2Dthree%20countries%20have%20eliminated,people%20remain%20threatened%20by%20NTDs.">countries</a> have eliminated at least one neglected tropical disease as a public health concern. Most recently the <a href="https://theconversation.com/how-the-gambia-beat-trachoma-an-infection-that-causes-blindness-160716">Gambia</a> and <a href="https://www.who.int/news/item/21-02-2022-who-validates-saudi-arabia-for-eliminating-trachoma-as-a-public-health-problem#:%7E:text=On%2026%20January%202022%2C%20the,Region%20to%20achieve%20this%20milestone.">Saudi Arabia</a> eliminated trachoma, a bacterial infection which causes blindness.</p>
<p>However, this progress is now at real risk of reversal as a result of the <a href="https://www.who.int/teams/control-of-neglected-tropical-diseases/overview/ntds-and-covid-19">COVID-19 pandemic</a>. Drug programmes have been interrupted, health budgets re-prioritised and aid cut.</p>
<p>As I have <a href="https://pubmed.ncbi.nlm.nih.gov/27988094/">previously highlighted</a>, interrupting control programmes could lead to rebound infections and disease. These could be worse than the original levels. This is now an imminent reality for neglected tropical diseases if control programmes do not resume quickly enough.</p>
<h2>Interrupted disease control</h2>
<p>One of the most important tools to use against neglected tropical diseases is <a href="https://www.sightsavers.org/protecting-sight/ntds/mass-drug-administration/">national mass drug administration</a>. This involves treating every member of a population, regardless of their infection status, because treatment is cheaper than diagnosis and the drugs are safe. Typically the national treatment programmes are annual events conducted in schools or health centres. It takes time, effort and money to plan and implement these programmes. And it’s critical to maintain momentum. Every dollar spent on these programmes yields a significant return on investment. This is why neglected tropical disease control has been termed a <a href="https://unitingtocombatntds.org/news/new-report-investments-neglected-tropical-diseases-are-one-best-buys-development/?lang=fr">“best buy” in development</a>.</p>
<p>The pandemic has affected neglected tropical disease control in three ways.</p>
<p>First, mass drug administration was <a href="https://schistosomiasiscontrolinitiative.org/about/how-money-is-spent">stopped or interrupted</a> by the <a href="https://rstmh.org/news-blog/news/covid-19-who-issues-interim-guidance-for-implementation-of-ntd-programmes">lockdown and social distancing policies</a>. And disruptions in global trade and transportation affected supply chains. A recent <a href="https://www.who.int/news/item/24-09-2021-neglected-tropical-diseases-2020-preventive-chemotherapy-treatment-coverage-declines-due-to-covid-19-disruptions#:%7E:text=The%20survey%20indicated%20that%2C%20as,highest%20among%20all%20health%20services.">World Health Organisation survey</a> indicated that, as of early 2021, disruptions in neglected tropical disease control programmes occurred in 44% of countries. </p>
<p>Second, national governments in neglected tropical disease endemic countries have low health budgets. <a href="https://www.nature.com/articles/s41591-021-01268-y">Changing priorities</a> during and after COVID-19 has meant that the resources allocated to neglected tropical diseases may be shifted to <a href="https://www.who.int/teams/control-of-neglected-tropical-diseases/overview/ntds-and-covid-19">other diseases and health services</a>.</p>
<p>Third, a significant amount of funding for neglected tropical disease control programmes comes from international development partners and foreign governments. Post-COVID-19 economic contraction in their economies and shifts in funding priorities are threatening the gains made in controlling neglected tropical diseases. For example, <a href="https://unitingtocombatntds.org/news/our-response-to-the-uks-cuts-to-foreign-aid/">the UK</a> recently withdrew over £150 million of funding to neglected tropical disease programmes as part of cuts to the country’s aid budget. This <a href="https://www.telegraph.co.uk/global-health/science-and-disease/uk-government-cuts-almost-wipe-funding-tackle-neglected-diseases/">wiped</a> out a third of donor funding for tackling neglected tropical diseases, with an impact on treatments to <a href="https://unitingtocombatntds.org/news/our-response-to-the-uks-cuts-to-foreign-aid/">250 million people</a> and as many as 180,000 surgeries to prevent disabilities. </p>
<h2>Long term consequences</h2>
<p>Continued neglect of these diseases has dire consequences. Those affected continue to suffer the devastating diseases, associated health inequities and cycles of poverty. The effects of these diseases are pervasive and wide-ranging. </p>
<p>As long as neglected tropical diseases are a huge burden on health systems in endemic countries, these countries will continue to haemorrhage resources, finances and lives to these diseases. This will further weaken their health systems, compromising their ability for timely surveillance, detection and containment of the next epidemic. From the <a href="https://ghsagenda.org/">Global Health Security Agenda</a>, we know that weakened health systems anywhere in the world compromise health security globally. Local health security is the foundation for global health security, as COVID-19 has amply demonstrated.</p>
<p>The opportunity to put global attention back on neglected tropical diseases will come later this year when the London Declaration is superseded by the <a href="https://idpjournal.biomedcentral.com/articles/10.1186/s40249-021-00932-2">Kigali Declaration</a>. This high-level political declaration, led by Rwanda and Nigeria, aims to mobilise political will and secure commitments to achieve <a href="https://sdgs.un.org/goals">Sustainable Development Goals targets</a> for these diseases. </p>
<p>It is important to remember that controlling neglected tropical diseases is in the best interest of all countries – those where the diseases are endemic and those where they are not.</p><img src="https://counter.theconversation.com/content/178324/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Francisca Mutapi receives research funding from the Royal Society in the UK,
She is board member for Uniting to Combat Neglected Tropical Diseases.</span></em></p>Progress against neglected tropical diseases is now at real risk of reversal as a result of the COVID-19 pandemic.Francisca Mutapi, Professor in Global Health Infection and Immunity. and co-Director of the Global Health Academy, The University of EdinburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1634412021-07-01T15:12:51Z2021-07-01T15:12:51ZCOVID-19 shows why Africa’s reliance on outsiders for health services is a problem<figure><img src="https://images.theconversation.com/files/409084/original/file-20210630-25-1mg1z1w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source"> Gecko Studio/Shutterstock</span></span></figcaption></figure><p>The COVID-19 pandemic has reinforced several truths about the detrimental effects of Africa being over reliant on western and international stakeholders to solve its health challenges and using western solutions to Africa’s health problems.</p>
<p>The continent has suffered heavily from the global COVID-19 supply chain <a href="https://hub.jhu.edu/2020/03/06/covid-19-coronavirus-impacts-global-supply-chain/">crisis</a>. Competitive procurement by governments with deeper pockets has hiked prices of vaccines while national export controls on essential commodities and raw materials have blocked access. These effects were recently <a href="https://www.news24.com/fin24/companies/health/rich-countries-deliberately-kept-vaccines-from-africa-says-telecoms-billionaire-strive-masiyiwa-20210623">highlighted</a> by the African Union special envoy, Strive Masiyiwa.</p>
<p>This is a manifestation of a much larger systemic problem. African countries rely heavily on western funding, products and approaches within their health systems. This includes preventative and diagnostic measures developed for western societies and cultures as well as interventions developed and optimised in the west. One example is the international criteria for the autoimmune disease lupus. My colleagues and I <a href="https://pubmed.ncbi.nlm.nih.gov/30245865/">recently</a> showed that these were set using predominantly white patients and did not capture the unique characteristics of the disease in black Africans. </p>
<p>Another problem is that relying on donor funding means that the funder ultimately determines the health priorities. This is one reason why many programmes in Africa focus on a single disease such as HIV. This approach allows impact evaluating and <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(97)90079-9.pdf">accountability</a>. But it leads to health workers and services specialised in managing a single disease.</p>
<p>Africa countries need integrated health systems in which priorities and services are decided on, led and owned locally. This is the approach being advocated for by the World Health Organisation for <a href="https://www.who.int/news-room/events/detail/2021/01/28/default-calendar/eliminating-ntds-together-towards-2030-formal-launch-of-the-new-road-map-for-neglected-tropical-diseases">neglected tropical diseases</a>. </p>
<p>Country leadership and ownership of health systems will only come if African governments step up to the plate. And if there’s private investment. Most African countries have pledged to set a target of allocating at least 15% of their annual budget to improve their <a href="https://africanarguments.org/2020/04/19-years-africa-15-health-abuja-declaration/">health sector</a>. <a href="https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?end=2018&locations=ZG&start=2018">None has achieved this</a>. </p>
<p>With the additional COVID-19 damage to health services in <a href="https://www.who.int/news/item/23-04-2021-covid-19-continues-to-disrupt-essential-health-services-in-90-of-countries">90%</a> of African countries, the need to prioritise health in government budget allocations has never been more urgent. </p>
<h2>Unique health needs</h2>
<p>The COVID-19 pandemic has illustrated how African countries have unique health needs. The continent’s population is younger, it has more infectious diseases, a larger rural population, uses both western and traditional medicine, and has cultural practices that affect disease risk.</p>
<p>African countries need a systemic approach targeting training, research, infrastructure, implementation and awareness programmes through the following three ways. </p>
<p>First, countries need to invest in training and retaining health personnel and services appropriate for their needs. Europe has about 40 doctors and 75 nurses per 10,000 people. <a href="https://www.who.int/data/gho/data/themes/topics/health-workforce">Africa has</a> about five doctors and 10 nurses per 10,000 people. This has meant that countries can’t rely on clinical staff for universal health coverage such as COVID-19 testing and screening. </p>
<p>Community health workers have become a critical part of the African health system delivering universal health coverage. They have played an important role in the <a href="https://gh.bmj.com/content/5/6/e002550">COVID-19 pandemic</a>. For example, South Africa drew on its <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7284159/">community-orientated primary care</a> staffed by community health workers for disease surveillance and testing.</p>
<p>They should be trained and rewarded appropriately to deliver other forms of interventions such as treatments for neglected tropical diseases and maternal health services. </p>
<p>Second, invest in and promote world class research on African health interventions including herbal medicines and traditional healers to solve African health problems. In Zimbabwe a novel way of providing mental health therapy is a good case in point. The country only has 17 registered psychiatrists for a population of <a href="https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30166-8/fulltext">15 million people</a>. A team drew on the African tradition of talking therapy that can be delivered by community health workers as an intervention for mental illness. This therapy, formalised through the <a href="https://www.centreforglobalmentalhealth.org/the-friendship-bench">Friendship Bench</a>, was used to deliver therapy to <a href="https://www.centreforglobalmentalhealth.org/the-friendship-bench">30,000 people in 2017</a>. </p>
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Read more:
<a href="https://theconversation.com/how-a-community-based-approach-to-mental-health-is-making-strides-in-zimbabwe-79312">How a community-based approach to mental health is making strides in Zimbabwe</a>
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<p>One reason the Friendship Bench has been successful is that its effectiveness has been evaluated <a href="https://jamanetwork.com/journals/jama/fullarticle/2594719">in clinical trials</a>. </p>
<p>A significant amount of research has been conducted on <a href="https://www.hindawi.com/journals/ecam/2013/617459/">herbal medicines</a> to identify active ingredients and mechanisms of action. But most have not undergone international standard clinical trials. As a result they are treated with suspicion and inferiority. This is a gap that needs to be filled.</p>
<p>But these trials should be conducted in Africa. This is because genetic, comorbidity and cultural disease risk factors in Africans differ from elsewhere.</p>
<p>For example, Africans are more likely to carry concurrent infectious diseases such as parasitic worms and malaria, possibly with HIV as an underlying condition. An example of different practices is that many women still prefer to deliver their babies with the help of <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-018-1691-7">traditional birth attendants</a>. </p>
<p>In addition, the African Union should insist that drug and vaccine trials carried out in Africa meet international standards to avoid repeating historical <a href="http://news.bbc.co.uk/2/hi/africa/6719141.stm">ethical concerns</a>. This will build trust which underlies willingness to participate in trials. </p>
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Read more:
<a href="https://theconversation.com/africa-must-make-sure-its-part-of-the-search-for-a-coronavirus-vaccine-136531">Africa must make sure it's part of the search for a coronavirus vaccine</a>
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<p>The African Union should also ensure Africans receive the full benefit from clinical trials conducted on the continent by negotiating access to the interventions before granting trial permissions. </p>
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Read more:
<a href="https://theconversation.com/south-african-covid-19-vaccine-trials-hold-key-lessons-for-future-partnerships-154676">South African COVID-19 vaccine trials hold key lessons for future partnerships</a>
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<p>Third, countries must create a permissive environment to support research and innovation. This includes intellectual property and medicines controls policies and competitive markets. Researchers in Africa have <a href="https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-020-04620-8">indicated</a> several barriers to running clinical trials including human capacity, delays in regulatory and ethical reviews, complex logistical and financial systems, bureaucracy and opaque procedures. </p>
<p>The continent already has frameworks for health innovations and most countries have medicines control authorities. These should now be harmonised at continental level through the <a href="https://joppp.biomedcentral.com/articles/10.1186/s40545-020-00281-9">Africa Medicines Agency</a> to facilitate sharing of best practices and transparency. <a href="https://www.nepad.org/news/pharmaceutical-manufacturing-plan-africa">The Pharmaceutical Manufacturing Plan for Africa</a> provides a vehicle for local pharmaceutical production, while the <a href="https://www.un.org/africarenewal/magazine/january-2021/afcfta-africa-now-open-business">African Continental Free Trade Area</a> agreement aims to make African industries more competitive on the global stage. Their implementation needs to be accelerated.</p>
<p>It is clear that as long as African countries don’t produce the health personnel and products Africa’s health system needs, they will be at the <a href="https://gh.bmj.com/content/6/6/e006362">back of the global queue</a> for resources produced abroad.</p><img src="https://counter.theconversation.com/content/163441/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Francisca Mutapi receives research funding from National Institute for Health Research (NIHR) through the (NIHR) Global Health Unit ‘Tackling Infectious Diseases to Benefit Africa' at the university of Edinburgh and The Royal Society through a International Collaborative Grant.
Current Board Memberships
Board Member – Uniting to Combat Neglected Tropical Diseases.
Current Membership of international expert/independent advisory committees
1. Sub-Committee for the Hideyo Noguchi Africa Prize, Japanese Government and WHO AFRO.
2. Scientific Advisory Board of the Else-Kröner-Center, Mwanza, Catholic University of Health and Allied Sciences, Tanzania
3. Royal Society of Edinburgh, Member, RSE Post-Covid Futures Commission - Building National Resilience.
4. UK Foreign, Commonwealth & Development Office (Formerly DFID) Science Advisory Group
5. UK Research and Innovation (UKRI) Global Challenges Research Fund Strategic Advisory Group
</span></em></p>Relying on donor funding means that the funder ultimately determines the health priorities. This is one reason why many programmes in Africa focus on a single disease such as HIV.Francisca Mutapi, Professor in Global Health Infection and Immunity. and co-Director of the Global Health Academy, The University of EdinburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1539142021-01-29T06:13:09Z2021-01-29T06:13:09ZInnovation – and research – are key to killing off neglected tropical diseases in Africa<figure><img src="https://images.theconversation.com/files/380888/original/file-20210127-19-11dkly6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A laboratory technician patient samples at the Amudat Hospital, Uganda. Laboratories are central to the delivery of high quality data in clinical trials.</span> <span class="attribution"><span class="source">Paul Kamau </span></span></figcaption></figure><p>As a young medical doctor over 30 years ago, I had an experience no doctor wants to have. One of my patients, a young boy, died in my arms as we rushed him to the referral hospital in Nairobi, Kenya, to receive treatment.</p>
<p>He had visceral leishmaniasis, a disease also known as kala-azar, which is transmitted by female sandflies. He had been brought 250 km from his village in Baringo because at that time the treatment was only available at our clinical trial site hospital in Nairobi. But we were too late.</p>
<p>Visceral leishmaniasis is an infectious disease that is not rare: <a href="https://www.sciencedaily.com/releases/2018/07/180726085645.htm">600 million people</a> in the world are at risk. Yet it is classified as a neglected tropical disease – a group of 20 preventable diseases that threatens more than 1.7 billion people globally. Africa carries <a href="https://www.afro.who.int/media-centre/statements-commentaries/africa-elimination-neglected-tropical-diseases-finally-within">almost 40%</a> of the worldwide burden.</p>
<p>In 2012 the World Health Organisation (WHO) <a href="https://www.who.int/neglected_diseases/NTD_RoadMap_2012_Fullversion.pdf">set targets</a> to control, eliminate or eradicate neglected tropical diseases. This attracted a lot of commitment and investments. <a href="https://unitingtocombatntds.org/progress/">More than 30 countries</a> have since eliminated at least one neglected tropical disease as a public health problem. For example, in 2020, Togo became the first African country <a href="https://www.afro.who.int/news/togo-first-african-country-end-sleeping-sickness-public-health-problem">to end sleeping sickness</a> as a public health problem. And Malawi is one of the countries that has <a href="https://www.who.int/news/item/29-10-2020-lymphatic-filariasis-reporting-continued-progress-towards-elimination-as-a-public-health-problem">eliminated elephantiasis</a>. </p>
<p>But there still aren’t enough tools to diagnose, treat, and prevent all these diseases. Neglected tropical diseases continue to cause tremendous suffering and death. Innovation is urgently needed to fill the diagnostic and treatment gaps and support is required for medical research.</p>
<h2>Challenges and progress</h2>
<p>These diseases <a href="https://www.who.int/news-room/q-a-detail/neglected-tropical-diseases">largely affect people</a> in the poorest regions, living in remote areas, urban slums or conflict zones. In many cases the only treatments that exist have a <a href="https://atm.eisai.co.jp/english/ntd/mycetoma.html">low cure rate</a> and some have <a href="https://dndi.org/diseases/chagas/facts/">side effects</a> so severe they can kill some patients. Effective, accessible, and safe treatments are sorely lacking.</p>
<p>Ineffective therapeutics are not only difficult for patients to take but also have a devastating impact on their social and economic life. For example, a patient with visceral leishmaniasis in Eastern Africa still has to spend <a href="https://www.afrikadia.org/afrikadia-project/treatment/">over 17 days in a hospital</a> to receive two daily injections of sodium stibogluconate and paromomycin. This is an improvement from the previous 30-day sodium stibogluconate injections alone, but patients must still endure the daily injections and hospitalisation throughout the treatment. </p>
<p>And in Sudan and neighbouring countries, <a href="https://dndi.org/stories/2016/mycetoma-the-faces-of-neglect/">mycetoma</a>, a disease transmitted by a simple thorn prick, slowly nibbles the flesh and limbs of a patient, before causing death. Existing treatments have only a 35% cure rate and amputation is usually the only “treatment” available.</p>
<p>But it’s not a hopeless situation.</p>
<p>One example is the advancement in the <a href="https://stories.dndi.org/sleepingsickness-doctors-dream/?fbclid=IwAR0xTLA5B_4BN_DPngjuXlWJWQE-b4yngyldRB6H1UDXB2atSOxuelQKh5g">treatment for second-stage sleeping sickness</a>. Previously, the treatment was a highly toxic drug that killed 1 in 20 patients. But my non-profit research and development organisation, the <a href="https://dndi.org/">Drugs for Neglected Diseases initiative</a> (DNDi), and its partners have developed a <a href="https://www.theeastafrican.co.ke/tea/science-health/and-now-a-new-drug-for-sleeping-sickness-1407518">simple all-oral treatment</a> that can cure all stages of the disease with just a few pills. </p>
<p>Another example is the treatment of visceral leishmaniasis. Twenty-two years ago the best treatment was a highly toxic 30-day treatment. Now there’s a <a href="https://www.theeastafrican.co.ke/tea/science-health/sand-fly-bringing-life-threatening-kalaazar-to-semi-arid-counties-1426824">17-day treatment</a>. Hospital stays are reduced and treatment is cheaper. <a href="https://dndi.org/press-releases/2019/wellcome-commits-10million-develop-new-generation-oral-drugs-leishmaniasis/">Clinical studies</a>for easy-to-administer oral treatments are currently in the initial stages.</p>
<p>One of the key ingredients for success has been sustained commitment to research, development and innovation. For example, in the Democratic Republic of Congo, new tools and unwavering control strategies have brought the number of <a href="https://www.who.int/health-topics/human-african-trypanosomiasis#tab=tab_1">new cases for sleeping sickness</a> down from tens of thousands per year to under 1,000.</p>
<p><a href="https://stories.dndi.org/sleepingsickness-doctors-dream/?fbclid=IwAR0xTLA5B_4BN_DPngjuXlWJWQE-b4yngyldRB6H1UDXB2atSOxuelQKh5g#group-the-clinical-sites-clSAiMizKr">Clinical trials</a> were successfully conducted in remote regions for a fraction of the traditional pharmaceutical cost and led to the development of the breakthrough drug fexinidazole. This was achieved through partnership between the Congolese government, local researchers, the pharmaceutical company Sanofi, and DNDi. </p>
<p>Partnerships like this demonstrate how far medical research and political leadership can go in addressing the needs of neglected patients.</p>
<h2>Looking ahead</h2>
<p>The WHO has set new targets to control and eliminate neglected tropical diseases by 2030 <a href="https://www.who.int/publications/i/item/WHO-UCN-NTD-2020.01">in a new Roadmap</a>.</p>
<p>African leaders have already shown the initial commitment. For the first time <a href="https://unitingtocombatntds.org/news/alma-ntds-2018/">a neglected tropical disease index</a> was included in the African Leaders Malaria Alliance scorecard for accountability and action two years ago. The inclusion of neglected tropical diseases was seen as recognition of the severity of these illnesses in member states. It provided a unique opportunity to increase political will, investment and <a href="https://alma2030.org/wp-content/uploads/2020/05/2.-2020-African-Union-Malaria-Progress-Report.pdf">accountability for these diseases</a>. </p>
<p>This was a good initial first step. </p>
<p>But current and future leaders need to be more involved. They can influence innovation and shape the policies that will lead to the control, elimination or eradication of neglected diseases. With commitment to find better tools that diagnose and treat these diseases, the unacceptable suffering of patients and neglected communities can finally be brought to an end.</p><img src="https://counter.theconversation.com/content/153914/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Monique Wasunna is the director of the Drugs for Neglected Diseases initiative Africa Regional Office.</span></em></p>Many of these diseases cause tremendous suffering and death – yet there’s still a lack of effective tools to diagnose, treat, and prevent them.Monique Wasunna, Researcher, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1483512020-11-10T10:18:28Z2020-11-10T10:18:28ZScabies: the neglected tropical disease no one wants to talk about<figure><img src="https://images.theconversation.com/files/367299/original/file-20201103-13-1jnfrxv.jpg?ixlib=rb-1.1.0&rect=7%2C7%2C5168%2C3437&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/girl-grey-shirt-scratching-her-arm-702122689">Mykola Samoilenko/Shutterstock</a></span></figcaption></figure><p>Some diseases are more likely to enter public conversation than others. COVID-19 has dominated the public discourse in 2020, while cancer and AIDS are high-profile diseases that attract significant scientific and media attention. You can safely discuss these diseases around the dinner table. Other diseases, such as scabies, not so much.</p>
<p>Scabies is classed as a neglected tropical disease. It’s out of sight and out of mind. But that doesn’t mean it isn’t there – there will be an infestation somewhere near you – take my word for it. </p>
<p>Scabies is caused by microscopic mites (<em>Sarcoptes scabiei</em>) that burrow under human skin and lay their eggs. The skin doesn’t take kindly to this infestation, which leads to an angry, itchy rash.</p>
<figure class="align-center ">
<img alt="An image of a scabies mite." src="https://images.theconversation.com/files/367301/original/file-20201103-23-1ghfn74.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/367301/original/file-20201103-23-1ghfn74.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/367301/original/file-20201103-23-1ghfn74.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/367301/original/file-20201103-23-1ghfn74.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/367301/original/file-20201103-23-1ghfn74.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/367301/original/file-20201103-23-1ghfn74.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/367301/original/file-20201103-23-1ghfn74.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The microscopic mite that causes untold misery to millions.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/scabies-sarcoptes-473745055">Blossom Tomorrow/Shutterstock</a></span>
</figcaption>
</figure>
<p>There are an estimated <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31136-5/fulltext">455 million cases of scabies</a> globally every year. That burden is unequally distributed, with poorer countries bearing the brunt of infestations. Yet even in wealthy countries, where most neglected tropical diseases are unheard of outside of travel clinics, scabies is present, often appearing as outbreaks in institutional settings, such as <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30347-5/fulltext">care homes for the elderly</a>. </p>
<p>It gets everywhere. While treatable, it is also <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1468-3083.2010.03618.x">stigmatised</a>, under-reported, often misdiagnosed, and the itch can be seriously unpleasant to bear. </p>
<h2>Stigma</h2>
<p>My team and I recently carried out research on <a href="https://academic.oup.com/trstmh/advance-article/doi/10.1093/trstmh/traa071/5898259?guestAccessKey=1652f0d0-f003-4731-942e-6b4710b2714f">scabies in Ghana</a>, describing how patients with scabies and other skin infections would travel further than necessary to report to a health centre. They bypassed their nearest centre, often heading for clinics several kilometres away, across difficult terrain. </p>
<p>The reasons for this are unclear. Colleagues in rural Ghana suggested that the day of the week that the patient reported to a clinic coincides with market day, and so the patient may combine a visit to the clinic and shopping in their nearest town during the one visit. Our statistical analysis did not bear this out, and we could not exclude the idea that patients would bypass their nearest health centre for reasons of stigma. </p>
<p>Scabies is sometimes perceived as an “unclean” condition, even in <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30500-0/fulltext">the published literature</a>, and the idea that washing is a cure is widespread. <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30558-9/fulltext">Bathing will not rid a patient of scabies</a> – but there are treatments that can clear it up. </p>
<p>In 2019, a <a href="https://web.archive.org/web/20190923232848/https:/www.myjoyonline.com/news/2019/September-21st/we-cant-sleep-at-night-how-scabies-outbreak-in-ne-region-is-spreading-deep-into-villages.php">huge outbreak of more than 6,000 cases of scabies</a> occurred in the north-east region of Ghana. The media reported how there was locally widespread fear at the transmission of skin rashes between villagers. A combination of misdiagnosis and misinformation resulted in some infected people being temporarily banished from their homes. </p>
<p>Local journalists met some of the patients, describing them as having “bloody open sores all over their bodies due to the excessive scratchings”. The outbreak was later correctly diagnosed and treatment was provided. But transmission to thousands of people shows the potential for large outbreaks to occur. An <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6306922/">Ethiopian outbreak</a> covered 379,000 cases of confirmed scabies. </p>
<p>In developed countries, the true prevalence is often unknown, but the institutional outbreaks can have a major <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30347-5/fulltext">health</a>, <a href="http://www.sciedu.ca/journal/index.php/jnep/article/view/13693">social</a> and <a href="http://www.sciedu.ca/journal/index.php/jnep/article/view/13693">economic</a> impact. </p>
<h2>Care homes</h2>
<p>Our <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30347-5/fulltext">study in The Lancet</a> showed how care home residents with dementia are more likely to end up with a scabies infection than those without dementia. Even in these settings of vulnerable populations, inequities still apply in terms of those most affected by infectious disease outbreaks. </p>
<p>Managing outbreaks in care homes is difficult and differs from how it is managed in other institutions, such as hospitals. A hospital ward is designed with infection control in mind, but care homes are quite literally that – people’s homes. </p>
<p>The COVID-19 pandemic has put these issues in a very harsh light with the thousands of excess deaths in care homes in countries such as the UK, Sweden and elsewhere. Managing scabies in the elderly is also not helped by ill-founded safety concerns about one of the main oral medicines, ivermectin. </p>
<p>A <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)63020-6/fulltext">1997 correspondence</a> in The Lancet reported increased mortality in care home residents being treated for scabies. It was <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)62377-X/fulltext">immediately criticised</a> for inadequate consideration of confounders (other factors that might have influenced the death of the resident, such as severity of dementia), and other outbreak reports have failed to confirm this association. </p>
<p>The WHO has endorsed ivermectin as safe and an essential medicine, but <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32619-4/fulltext">it remains unlicensed</a> for scabies treatment in the UK and is rarely used despite being safe and effective. And, as an oral medicine, it is easier to use than skin creams, such as permethrin.</p>
<p>Scabies doesn’t kill many people and it doesn’t attract headlines, but don’t underestimate the power of the itch. It makes life seriously unpleasant for those with the infection and can lead to stigma and poor quality of life. Multiply that one case you are thinking of by 455 million, and there you have the global annual picture.</p><img src="https://counter.theconversation.com/content/148351/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Head has received funding for scabies research from the University of Southampton Strategic Development Fund, and was part of a scabies care home study funded by the Health Protection Agency. </span></em></p>Every year, around 455 million get scabies. Not that you’d know, because no one talks about it.Michael Head, Senior Research Fellow in Global Health, University of SouthamptonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1274222020-01-17T13:55:16Z2020-01-17T13:55:16ZIdentifying aquatic plants with drones could be the key to reducing a parasitic infection in people<figure><img src="https://images.theconversation.com/files/308128/original/file-20191220-11929-1sl0j2o.jpg?ixlib=rb-1.1.0&rect=15%2C9%2C2029%2C1523&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Researchers operate inexpensive drones to 'see' the areas with the highest likelihood of parasites.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/chelsealwood/34251500273/in/album-72157681532310374/">Chelsea L. Wood/University of Washington</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><p>For the majority of people on Earth, parasites are a fact of life. These organisms live inside the human body, causing debilitating or fatal diseases. Among the parasitic diseases, one of the very worst is <a href="https://www.cdc.gov/parasites/schistosomiasis/index.html">schistosomiasis</a>, caused by worms living in the human circulatory system. The disease can cause bleeding, organ damage, and elevated risk of HIV infection and cancer. For children, infection can stunt growth and impair cognitive development. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/307946/original/file-20191219-11900-eyeje2.jpg?ixlib=rb-1.1.0&rect=18%2C36%2C1515%2C2009&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/307946/original/file-20191219-11900-eyeje2.jpg?ixlib=rb-1.1.0&rect=18%2C36%2C1515%2C2009&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/307946/original/file-20191219-11900-eyeje2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307946/original/file-20191219-11900-eyeje2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307946/original/file-20191219-11900-eyeje2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307946/original/file-20191219-11900-eyeje2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307946/original/file-20191219-11900-eyeje2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307946/original/file-20191219-11900-eyeje2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Everyday chores can carry a risk of parasitic exposure for Senegalese villagers.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/chelsealwood/35062512055/in/album-72157681532310374/">Chelsea L. Wood/University of Washington</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>Schistosome worms infect more than <a href="https://www.who.int/news-room/fact-sheets/detail/schistosomiasis">200 million people globally</a>, most of whom live in sub-Saharan Africa. People become infected with this parasite through contact with contaminated freshwater. The worm penetrates their skin as they bathe, perform agricultural work or carry out domestic chores like washing clothes.</p>
<p>There is no vaccine. Since the 1980s, efforts to eliminate schistosomiasis have primarily focused on distributing drugs to infected people. But recently, the <a href="https://www.who.int/">World Health Organization</a> formally recognized that this strategy <a href="https://apps.who.int/iris/handle/10665/78074">isn’t working</a> in many places, because the treatment provides no protection against future infections. People can rapidly become re-infected when they again come into contact with contaminated water.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/307934/original/file-20191219-11939-1vfwq9y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/307934/original/file-20191219-11939-1vfwq9y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/307934/original/file-20191219-11939-1vfwq9y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307934/original/file-20191219-11939-1vfwq9y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307934/original/file-20191219-11939-1vfwq9y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307934/original/file-20191219-11939-1vfwq9y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307934/original/file-20191219-11939-1vfwq9y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307934/original/file-20191219-11939-1vfwq9y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Kids in Maka Diama, Senegal.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/chelsealwood/22616952525/in/album-72157660524369226/">Chesea L. Wood/University of Washington</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>In addition to drug distribution, WHO emphasizes controlling the snails that incubate the parasitic schistosome worms. The idea is that eliminating the snails could eliminate the disease, since the worms wouldn’t be able to live and replicate in freshwater without them. Although public health officials know eradicating these snails can be a way to manage the schistomosiasis parasite, the challenge is to locate hotspots where the snails flourish.</p>
<p><a href="https://chelsealwood.wordpress.com/">My lab</a> uses ecology, the scientific study of the abundance and distribution of organisms, to develop solutions for infectious diseases. <a href="http://www.theupstreamalliance.org">My colleagues and I</a> work to help public health agencies identify where schistosomiasis hotspots are located. Recently, we made a surprise discovery involving aerial images of aquatic vegetation taken by drones, an approach that may help public health officials gain some real traction in reducing schistosomiasis burdens. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/uoWQDA1Syok?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<h2>Interrupting the life cycle of a parasite</h2>
<p>Most of the parasitic <a href="https://www.who.int/neglected_diseases/diseases/en/">tropical diseases</a> that infect humans are caused by worms with complex life cycles. The link between humans and parasites is the environment. The environment, therefore, is key to reducing transmission of schistosomiasis to people. Since 2014, <a href="https://chelsealwood.wordpress.com/research/diversity-and-human-infectious-disease/">my lab</a> and <a href="http://www.theupstreamalliance.org">our collaborators</a> have worked at the site of the world’s largest recorded schistosomiasis epidemic, the <a href="https://www.google.com/maps/place/Lac+de+Guiers/@16.1817404,-16.1451939,10z/data=!3m1!4b1!4m5!3m4!1s0xe95242e2c6da065:0x298337258282a457!8m2!3d16.2247443!4d-15.8407722">Lower Senegal River Basin</a> in Senegal, West Africa. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/307959/original/file-20191219-11904-5tpq4l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/307959/original/file-20191219-11904-5tpq4l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/307959/original/file-20191219-11904-5tpq4l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307959/original/file-20191219-11904-5tpq4l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307959/original/file-20191219-11904-5tpq4l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307959/original/file-20191219-11904-5tpq4l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307959/original/file-20191219-11904-5tpq4l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307959/original/file-20191219-11904-5tpq4l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A team of Senegalese and U.S. researchers inspect vegetation for snails.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/chelsealwood/27406778881/in/album-72157666764605683/">Chelsea L. Wood/University of Washington</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>When our project began, our goal was to map when and where snails occurred at water-access sites used by villagers. Snails cluster, and we reasoned that once we identified the locations of those clusters, a Senegalese public health team could destroy them by physically removing the snails or using chemical <a href="https://www.who.int/schistosomiasis/resources/9789241511995/en/">molluscicides</a>. Limiting the size of the targeted area would lower the cost to control the snail populations by reducing the expense and environmental and health impacts of application. </p>
<p>Unfortunately, snails don’t stay put. <a href="https://doi.org/10.1073/pnas.1903698116">Our research</a> indicated that targeting snail clusters might not be an efficient way to get rid of them. In fact, it was rare for a snail cluster that we found during one field trip to be present when we returned just a few months later. We went back to the drawing board.</p>
<p>Our team had been using drones to get an aerial image of the aquatic habitat at each water-access site. We noticed that snails tended to associate with certain kinds of aquatic vegetation that were visible in our drone imagery. This realization allowed us to make an important discovery: human schistosomiasis infections were more common at sites where this suitable snail habitat was present. </p>
<h2>Surveillance with inexpensive technology</h2>
<p>This finding led our team to two important realizations.</p>
<p>First, public health agencies in Senegal might be able to prioritize their drug distribution strategy with the help of drone imagery. Getting drugs to those who need them most is important, given that most heavily infected villages tend to be poor, extremely remote, and difficult or expensive to access.</p>
<p>Consumer-grade drones are affordable and may reduce the time and effort needed to evaluate the health of people living in remote villages. The aquatic plants in waterways are easy to see from the air. They can provide a visual proxy for where schistosome-carrying snails are located, suggesting that there may be higher human infection rates in that area. That information could lead to better data on the distribution of human infections and, therefore, to more efficient drug allocation. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/BAJm3XYzKUc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Drone flyover of Mbarigot, a village outside of the city of Saint Louis, Senegal. (Andrew J. Chamberlin, Stanford University)</span></figcaption>
</figure>
<p>Second, while we found that it would be impractical to identify and target snail clusters, it could be efficient to target the vegetation that serves as snail habitat. Molluscicide could be applied to patches of this vegetation to destroy any snails within. Another option would be to physically remove the vegetation. Our team is testing the effectiveness of removing vegetation to reduce snail abundance and human infection burden. </p>
<p>Ecology is the bottleneck on progress toward the control and elimination of many infectious diseases, including schistosomiasis. Questions remain about the relative costs and benefits of altering the environment to reduce infectious disease transmission. Our aim is provide the best available data to the people whose lives and livelihoods are affected, so that they can make informed choices about how to ensure a healthy future for themselves and their children.</p>
<p>[ <em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=youresmart">You can read us daily by subscribing to our newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/127422/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chelsea L. Wood receives funding from the US National Science Foundation (OCE-1829509, DGE-1922004), the Alfred P. Sloan Foundation (Sloan Research Fellowship), the Western Regional Aquaculture Center (USDA, NIFA), Washington Sea Grant, Oceans Initiative, the University of Washington President's Innovation Initiative (UW Innovation Award), and the University of Washington Royalty Research Fund. </span></em></p>Schistosome worms infect hundreds of millions of people worldwide. Researchers have discovered how to use inexpensive drones to identify disease hotspots in remote African villages.Chelsea L. Wood, Assistant Professor of Aquatic and Fishery Sciences, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1222942019-09-16T12:02:24Z2019-09-16T12:02:24ZThere’s a way for modern medicine to cure diseases even when the treatments aren’t profitable<figure><img src="https://images.theconversation.com/files/291774/original/file-20190910-190035-le6o0h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Millions of young children get malaria. These two got it in 2010.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congo-South-Africa-Malaria-Vaccine/3260199e339e4cb893eca38e5580e2e8/1/0">AP Photo/Schalk van Zuydam </a></span></figcaption></figure><p>Strides in medicine have contributed to a <a href="https://ourworldindata.org/grapher/life-expectancy-globally-since-1770">dramatic increase in life expectancy</a> over the last century. Diseases like <a href="https://time.com/4585537/world-aids-day-hiv/">HIV</a> and <a href="https://report.nih.gov/nihfactsheets/viewfactsheet.aspx?csid=76">cervical cancer</a> that were essentially death sentences as recently as 30 years ago can now be managed with access to prescription drugs and surgical procedures.</p>
<p>Yet previously unknown or undiagnosed diseases and conditions continue to appear. And there are few to no effective treatments for many diseases and conditions.</p>
<p>Especially when the people susceptible to those illnesses tend to be <a href="https://www.clinipace.com/low-income-countries-severely-affected-infectious-diseases/">low-income</a>, the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3327542/">costly</a> fight to find cures and develop vaccines for those diseases are unlikely to be <a href="https://www.bloomberg.com/news/articles/2019-05-03/antibiotics-aren-t-profitable-enough-for-big-pharma-to-make-more">profitable</a>.</p>
<p>That is why I believe nonprofits have a vital role to play in funding these endeavors.</p>
<h2>No ‘moonshot’</h2>
<p>The research I have engaged in for most of my career as a <a href="https://scholar.google.com/citations?user=N4_3qVkAAAAJ&hl=en&oi=sra">medicinal chemist</a> has been focused on drug discovery. Much of these efforts have been aimed at treating <a href="https://www.exelixis.com/cabozantinib-development-program/">cancer</a> and <a href="https://ir.exelixis.com/news-releases/news-release-details/exelixis-collaborator-daiichi-sankyo-launches-minnebror">cardiovascular disease</a>.</p>
<p>More innovation is required for the development of new drugs that can, to name two examples, keep <a href="https://doi.org/10.1377/hlthaff.28.4.949">malaria</a> and <a href="https://dx.doi.org/10.1016%2Fj.pt.2018.07.007">dengue fever</a> at bay.</p>
<p>Unfortunately, despite the desperate need for drugs for other illnesses that mostly afflict the poor, most drugmakers are not <a href="https://www.nationalgeographic.com/science/phenomena/2015/05/23/oneill-amr-3/">pursuing new methods for treating them</a>. That is, there is no “<a href="https://www.cancer.gov/research/key-initiatives/moonshot-cancer-initiative">moonshot</a>” aimed at curing and preventing these illnesses being funded by the private sector.</p>
<p>And while federal agencies like the National Institutes of Health do provide funding for the study of <a href="https://www.hhs.gov/about/budget/fy2018/budget-in-brief/nih/index.html">infectious diseases and neurological disorders</a>, neither have adequate funding. </p>
<p>The problem is that <a href="https://www.medpagetoday.com/blogs/revolutionandrevelation/72407">private companies are largely obligated to maximize their profits</a> no matter what they produce. It therefore seems unreasonable to expect drug companies to work in areas that they suspect will not earn any money in the long run, if ever.</p>
<h2>$1.4 billion</h2>
<p>Let’s say the president of Pfizer were to announce tomorrow that the company is going to invest heavily in <a href="https://www.theguardian.com/world/2019/aug/23/malaria-will-not-be-eradicated-in-near-future-warns-who">eradicating malaria</a>. They would likely be nominated for the Nobel Peace Prize. However, the company might immediately start looking for a new top executive since eradicating malaria would easily cost Pfizer more than it could possibly recoup in sales. </p>
<p>A 2016 report by the <a href="https://doi.org/10.1016/j.jhealeco.2016.01.012">Tufts Center for the Study of Drug Development</a> estimated the cost of developing an FDA-approved prescription drug is US$1.4 billion. Production, shipping or any type of sales cost even more.</p>
<p>Meanwhile, those at the greatest risk of contracting malaria live in countries where the <a href="http://global-growing.org/en/content/fact-7-about-three-quarters-african-population-live-less-2-half-population-less-125-day">average annual income can be less than $1,000</a>. The prospects of being able to recover even a small fraction of that investment are <a href="https://health-e.org.za/2001/10/26/no-new-drugs-for-unprofitable-diseases-of-developing-world/">extremely slim</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/291644/original/file-20190909-109915-18lt48x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/291644/original/file-20190909-109915-18lt48x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/291644/original/file-20190909-109915-18lt48x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/291644/original/file-20190909-109915-18lt48x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/291644/original/file-20190909-109915-18lt48x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/291644/original/file-20190909-109915-18lt48x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/291644/original/file-20190909-109915-18lt48x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/291644/original/file-20190909-109915-18lt48x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Bringing a new drug to market from experimentation through marketing costs a small fortune.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/flask-scientist-hand-dropping-chemical-liquid-457937065?src=1-SETlpvTrCJ8KDprGS8uQ-1-34">totojang1977/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Superbugs</h2>
<p>Before you dismiss this as a problem unlikely to affect your own well-being, consider the health risks posed by <a href="https://www.cdc.gov/features/antibiotic-resistance-global/index.html">antibiotic resistance</a>.</p>
<p>The development of bacterial resistance to common drugs like <a href="https://www.drugs.com/article/antibiotic-resistance.html">amoxicillin</a>, <a href="https://www.webmd.com/sexual-conditions/antibiotic-resistant-std-faq">azithromycin</a> and other similar drugs has given rise to the discovery of other drugs such as <a href="https://www.mdedge.com/ccjm/article/95526/drug-therapy/vancomycin-50-something-year-old-antibiotic-we-still-dont-understand">vancomycin</a> and <a href="https://www.britannica.com/science/methicillin">methicillin</a>. However, new strains of bacteria have come along that are <a href="https://www.the-hospitalist.org/hospitalist/article/121560/antimicrobial-resistant-infections/superbug-infections-rise-no-antibiotic">resistant to even these last lines of defense</a>. </p>
<p>Modern medicine has no known treatments against these so-called “superbugs.”</p>
<p>Absent new drugs to treat such infections, a person who gets a scratch that becomes infected could be at risk of dying. </p>
<p>With that in mind, there is a clear need for new antibiotic drug discovery. Yet <a href="https://www.businessinsider.com/major-pharmaceutical-companies-dropping-antibiotic-projects-superbugs-2018-7">virtually all drugmakers have moved away from this line of business</a> for one obvious reason.</p>
<p>If a new drug were identified tomorrow, it would obviously be held out as the new <a href="https://www.healthcaredive.com/news/without-more-stewardship-superbugs-could-kill-thousands-more-americans-ann/541832/">last line of resistance</a> for the treatment of bacterial infections. How could a company justify spending the requisite $1.4 billion to develop a drug that would only be used as a drug of last resort?</p>
<p>If, say, 1,000 patients needed the drug in a given year, could a company realistically expect each patient over 10 years to pay $140,000 just to recover the initial cost of the discovery? Of course not. But it might make sense for nonprofits to do this if that’s their mission.</p>
<h2>Promising examples</h2>
<p>There are nonprofits who engage in drug discovery for these neglected diseases. One good example is <a href="https://www.mmv.org/">Medicines for Malaria Venture</a>, a group of scientists based in Switzerland dedicated to reducing the burden of malaria on a global scale. </p>
<p><a href="https://www.gatesfoundation.org/">The Bill and Melinda Gates Foundation</a>, <a href="https://www.oneworldhealth.com/">OneWorld Health</a>, the <a href="https://www.newtbdrugs.org/">Working Group on New Tuberculosis Drugs</a> and the <a href="https://www.milkeninstitute.org/centers/center-for-public-health">Milken Institute Center for Public Health</a> are among the best-known organizations working to realize these important goals <a href="https://www.mmv.org/partnering/our-donors/current-donors">without being subjected to stockholder pressure</a>.</p>
<p>These efforts have given rise to <a href="https://www.mmv.org/research-development/mmv-supported-projects">nearly a dozen new approved drugs to treat malaria</a>, and they have made progress toward creating vaccines that might stem the spread of diseases like <a href="https://www.who.int/csr/resources/publications/ebola/ebola-ring-vaccination-results-12-april-2019.pdf">Ebola</a> and <a href="https://www.nih.gov/news-events/news-releases/nih-begins-clinical-trial-live-attenuated-zika-vaccine">Zika</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/291643/original/file-20190909-109927-1vxzs3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/291643/original/file-20190909-109927-1vxzs3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/291643/original/file-20190909-109927-1vxzs3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=375&fit=crop&dpr=1 600w, https://images.theconversation.com/files/291643/original/file-20190909-109927-1vxzs3z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=375&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/291643/original/file-20190909-109927-1vxzs3z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=375&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/291643/original/file-20190909-109927-1vxzs3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=471&fit=crop&dpr=1 754w, https://images.theconversation.com/files/291643/original/file-20190909-109927-1vxzs3z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=471&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/291643/original/file-20190909-109927-1vxzs3z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=471&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The bacteria that causes tuberculosis.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/bacteria-mycobacterium-tuberculosis-causative-agent-3d-1013219203?src=qmHc3gUU1FUp62X5iZ4ujw-1-1">Kateryna Kon/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>The <a href="https://www.tballiance.org/">TB Alliance</a> is an international nonprofit dedicated to the discovery, development and delivery of better, faster-acting and affordable tuberculosis drugs that are available to <a href="https://www.cdc.gov/tb/statistics/default.htm">those who need them</a>.</p>
<p>With support from the <a href="https://www.tballiance.org/about/donors">Gates Foundation</a> and government agencies from around the world, the alliance gained FDA approval for <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-new-drug-treatment-resistant-forms-tuberculosis-affects-lungs">pretomanid</a>, its new drug that can treat multidrug-resistant TB, which an estimated <a href="https://www.who.int/tb/areas-of-work/drug-resistant-tb/en/">600,000 people develop every year</a>.</p>
<p>What I found to be especially noteworthy is that the alliance facilitated and funded the efforts that resulted in a new lifesaving treatment without creating its own lab. Instead, it coordinated the efforts of other researchers already conducting TB investigations in many countries. </p>
<p>The continued support by government agencies, private donors and nonprofits of these ventures could prove paramount to the survival of the human species. While their continued funding is clearly needed to provide these critical medicines, all of us are fortunate to have organizations such as this working for the betterment of mankind.</p>
<p>[ <em><a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=expertise">Expertise in your inbox. Sign up for The Conversation’s newsletter and get a digest of academic takes on today’s news, every day.</a></em> ]</p><img src="https://counter.theconversation.com/content/122294/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Leahy owns shares of stock in a variety of pharmaceutical companies, including Exelixis, where he worked for 14 years. His research is funded in part by funding agencies such as the National Institutes of Health and the National Science Foundation.</span></em></p>There’s a big market for new treatments for TB, malaria and other ailments. But most of these diseases afflict low-income people unable to pay for medicine.James Leahy, Professor of Chemistry; Interim Chair of the Chemistry Department, University of South FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1031112018-09-16T06:29:46Z2018-09-16T06:29:46ZClimate change, water and the spread of diseases: connecting the dots differently<figure><img src="https://images.theconversation.com/files/236005/original/file-20180912-133880-4hoc6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Climate change also has an impact on public health.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/329474339?src=uWI_5Ss8htsMlQY2hG52Dw-1-30&size=medium_jpg">Shutterstock</a></span></figcaption></figure><p>Half a century ago concerns about climate change, environment vulnerability, population density and the sustainability of earth systems reached a broad audience. This was clear from books like the <a href="http://www.rachelcarson.org/SilentSpring.aspx">Silent Spring</a> published in 1962, and <a href="http://www.ask-force.org/web/Global-Warming/Meadows-Limits-to-Growth-Short-1972.pdf">The Limits to Growth</a> published 10 years later.</p>
<p>These works influenced environmental activism at the time. They also laid the foundations for growing <a href="http://www.pnas.org/content/115/33/8252">scientific</a> <a href="http://advances.sciencemag.org/content/3/5/e1600871">evidence</a> <a href="http://iopscience.iop.org/article/10.1088/1748-9326/aa6825">that climate change</a> was happening and was negatively affecting the earth.</p>
<p>But one piece of the puzzle has been missing: the impact of climate change on people, and specifically, on public health.</p>
<p>This changed at the beginning of this century with growing advocacy and gatherings such as the <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/29610376/">Conference of Parties</a> and the publication of <a href="https://www.ecologyandsociety.org/vol14/iss2/art32/">new research</a>. Scientists began writing about the earth moving into a new era called the <a href="https://www.smithsonianmag.com/science-nature/what-is-the-anthropocene-and-are-we-in-it-164801414/">Anthropocene</a>. This is an era in which ecosystems were increasingly being affected by human behaviour, and in which people were being affected by the changes brought about by their actions. </p>
<p>The Anthropocene provided the impetus for renewed attention on health and sustainability for all species. This new understanding led to increasing new research, across disciplines, to new interdisciplinary journals, and to policy documents on the impact of climate change on health. Major new insights began to emerge. These included the fact that changes in weather patterns were affecting the behaviour of mosquitoes. This in turn was affecting our ability to control disease. A raft of work also started to emerge on the affects of changing weather patterns, heat waves, and access to clean water on people’s health. </p>
<p>The next step along this journey was that academics came to realise that they can’t work in disciplinary silos. For example, health scientists came to grasp that they need anthropologists, sociologists and economists for a full understanding of the impact of climate change. The circle of knowledge has, as a result, begun to expand.</p>
<p>Parallel to these efforts, artists and advocacy groups have worked to keep climate change on international and national policy agendas. For example, artists have taken inspiration and drawn from scientific research in engineering, chemistry, biology, and the earth sciences to make their art. In a first of its kind on the African continent, these efforts are reflected at a 10-day public and <a href="https://www.wits.ac.za/watershed/">academic programme</a> at the University of the Witwatersrand. The programme enmeshes art and science to provoke new thinking about water and how its politicisation affects public health.</p>
<h2>Insights from different disciplines</h2>
<p>Extreme weather events, shifts in temperature variation and precipitation, and higher mean temperatures have dramatically affected human health and well-being. </p>
<p>From a health perspective, incremental environmental changes over time have undone decades of investment in the control of infectious diseases. Many of these are water-borne and water-washed diseases, such as dysentery and scabies. They are result of poor personal hygiene because of inadequate water availability. These diseases, common throughout Africa, are often described as neglected diseases of poverty.</p>
<p>Scientists have started to explore the various affects in different settings in relation to different diseases. </p>
<p>For example, changes in temperature and rainfall have, in turn, changed the behaviour of vectors such as <a href="https://www.ncbi.nlm.nih.gov/pubmed/29274851">mosquitoes</a>, <a href="https://parasitesandvectors.biomedcentral.com/articles/10.1186/s13071-018-3019-x">flies</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/22142789">snails</a>, with other factors complicating the spread of disease (for a summary, <a href="https://idpjournal.biomedcentral.com/articles/10.1186/s40249-017-0378-z">see</a>). This means the settings that create the conditions for debilitating and potentially fatal diseases such as malaria, zika, and dengue have shifted. For example, mosquitoes have moved to new areas, introducing infection to previously unaffected people and certain animals.</p>
<p>Anthropologists have used a different lens to understand the impact. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2643480/">Research</a> shows that inequality influences people’s exposure to vector-borne diseases and other environmentally sensitive infections. <a href="https://www.cmcc.it/publications-type/referred-paper">Gender, class and age</a> have also emerged as points of vulnerability for disease and poor health in the context of climate change. </p>
<p>Climate change has, most notably, begun to affect weather patterns. Changes in precipitation and quantity, floods and droughts, and water insecurity are increasingly common as the planet warms. </p>
<p>Scientists have begun to track how this affects food production and other farming <a href="https://www.annualreviews.org/doi/abs/10.1146/annurev-environ-021810-094524">activities</a>. This in turn affects people’s livelihoods and food security. These changes are increasingly being followed not just by climate scientists, but also by academics from disciplines as wide-ranging as economics and politics. This follows the realisation that challenges of ageing infrastructure and water governance, for example, complicate finding solutions to overcoming the challenges posed by global warming.</p>
<h2>Creative interventions</h2>
<p>Scientists across disciplines – social, biological, and physical sciences as well as the humanities and arts – need to continue to work on ways to interrupt disease transmission in the context of global warming. They seek to identify appropriate interventions where climate change affects health – and to come up with creative solutions that cut across narrow paths of thinking.</p>
<p>Artists and civil society have a key role to play by creating narrative, visual and acoustic forms to support advocacy on issues of climate change, pollution, the ecology and environmental justice.</p><img src="https://counter.theconversation.com/content/103111/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lenore Manderson has received research funding from the Australian Research Council and more recently, the South African National Research Foundation. She has been an advisor to Special Programme for Research and Training in Tropical Diseases (TDR) for the past 30 years.</span></em></p>Scientists need to continue working across disciplines to find ways to disrupt disease transmission in the context of climate change.Lenore Manderson, Visiting Distinguished Professor of Environmental Studies, Brown University, USA, and Distinguished Professor, Public Health and Medical Anthropology, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/841772017-10-25T00:12:06Z2017-10-25T00:12:06ZWhy aren’t we curing the world’s most curable diseases?<figure><img src="https://images.theconversation.com/files/192150/original/file-20171027-13355-fxyqq9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some tropical diseases can be treated with very inexpensive daily treatments yet remain common. </span> <span class="attribution"><span class="source">Avatar_023/Shutterstock.com</span></span></figcaption></figure><p>Once upon a time, the world suffered.</p>
<p>In 1987, 20 million people across the world were plagued by a debilitating, painful and potentially blinding disease called river blindness. This parasitic infection caused pain, discomfort, severe itching, skin irritation and, ultimately, <a href="http://www.who.int/neglected_diseases/diseases/NTD_Report_APPMG.pdf">irreversible blindness</a>, leaving men, women and children across Africa unable to work, care for their families and lead normal lives.</p>
<p>But the recent discovery of a drug called ivermectin was about to change it all. Not only was ivermectin cheap and easily synthesized, but it was also a powerful cure: With only one dose a year, it was possible to completely rid patients of disease and even halt the progression toward blindness. In short, ivermectin was a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043740/">miracle drug</a> – one whose discovery would lead to Satoshi Omura and William Campbell winning the Nobel Prize in medicine in 2015.</p>
<p>There was no time to be wasted. Recognizing that the populations most at risk of disease were those least able to afford treatment, Merck & Co. <a href="http://www.nytimes.com/1987/10/22/world/merck-offers-free-distribution-of-new-river-blindness-drug.html">pledged to join the fight to end river blindness</a>. Thirty years ago this October, the pharmaceutical company vowed that it would immediately begin distributing the drug free of charge, to any country that requested it, “<a href="http://www.who.int/neglected_diseases/diseases/NTD_Report_APPMG.pdf">for as long as needed</a>.” It was the final piece of the puzzle: an effective drug for a tragic and completely preventable disease. And we all lived happily ever after.</p>
<p>Only… we didn’t.</p>
<p>Merck’s generous offer should have been the final chapter of a brief story with an upbeat ending – the eradication of a tragic and preventable disease that had plagued humankind for centuries. But such was not the case: 30 years later, in 2017, river blindness rages on across the world, afflicting as many as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3125028/">37 million people</a>, 270,000 of whom have been left permanently blind.</p>
<p>Neglected tropical diseases like river blindness stand in stark contrast to those like tuberculosis, which is estimated to affect <a href="http://www.who.int/mediacentre/factsheets/fs104/en/">a third of the world’s population</a> due to the increasing prevalence of highly antibiotic resistant strains.</p>
<p>In short, tuberculosis has stuck around because medicine has run out of drugs with which to treat it – which is why, as a molecular biologist, I am researching new ways we can finally defeat this stubborn disease. </p>
<p>But this only increases the urgency for river blindness and other widespread diseases for which, unlike tuberculosis, science does have effective cures – and inexpensive ones at that. Even with all the necessary tools, the world has failed to cure the curable. </p>
<h2>Turning a blind eye</h2>
<p><a href="http://www.end.org/whatwedo/ntdoverview">One-and-a-half billion people</a> across the world suffer from neglected tropical diseases, a group of infectious diseases that prevail in tropical and subtropical countries lacking good health care infrastructure and medical resources. These diseases typically do not kill immediately but instead blind and disable, leading to terrible suffering, creating losses of capital, worker productivity and economic growth.</p>
<p><a href="http://www.nejm.org/doi/full/10.1056/NEJMra064142">Thirteen diseases</a> are universally recognized as neglected tropical diseases. At least eight of these diseases, including river blindness, already have inexpensive, safe and effective treatments or interventions.</p>
<p>For less than 50 cents per person, the United States could cure a fifth of the world’s population of these severely debilitating and unnecessary diseases. In spite of this, the United States allocates nearly as little to treating and preventing neglected tropical diseases around the world as it does to <a href="http://www.cbsnews.com/news/pentagon-spends-a-lot-of-money-on-viagra/">drugs for erectile dysfunction</a>.</p>
<h2>The forgotten fevers</h2>
<p>Consider dracunculiasis, or Guinea worm infection, which occurs when people consume water contaminated with fleas carrying parasitic worms. The worms mature and mate inside the human body, where they can grow to be <a href="http://www.cdc.gov/parasites/guineaworm/gen_info/faqs.html">two to three feet long</a>. </p>
<p>Adult females eventually emerge from painful blisters at the extremities to lay eggs in stagnant water, where offspring will infect water fleas and begin the cycle anew.</p>
<p>No drug exists that can cure Guinea worm, but because of a cohort of mostly privately funded public health efforts, the number of Guinea worm infections worldwide has dropped from <a href="https://www.cartercenter.org/health/guinea_worm/case-totals.html">3.5 million in the 1980s to only 25 in 2016</a>.</p>
<p>Funding from the U.S. and other countries could help in the final push to eradication, and some argue that <a href="https://theconversation.com/african-academics-set-out-what-dr-tedros-needs-in-his-toolbox-to-tackle-health-ills-80898">funding from the individual countries</a> themselves could help. </p>
<p>Another example, albeit more grim, is the group of soil-transmitted helminths, or worms. Roundworm, hookworm and whipworm collectively affect over a billion people across the world, all in the poorest areas of the poorest countries. All these worms infect the human intestines and can cause severe iron deficiency, leading to increased mortality in pregnant women, infants and children. Furthermore, hookworm infections in children <a href="http://www.newyorker.com/tech/elements/war-of-the-worms">retard growth and mental development</a>, leading to absences from school and dramatically reduced labor productivity.</p>
<p>However, soil-transmitted helminths can be expelled from the body with a single pill, each of which costs <a href="http://www.who.int/neglected_diseases/diseases/NTD_Report_APPMG.pdf">only one penny</a>. What’s more, preventing infection in the first place is completely achievable through increased awareness and sanitation.</p>
<h2>The purse strings of nationalism</h2>
<p>Without drastic increases in funding and public awareness, the plight of people affected by the neglected tropical diseases is unlikely to budge anytime soon.</p>
<p>The U.S. spends <a href="http://www.who.int/mediacentre/factsheets/fs319/en/">over US$8,000</a> per person per year on health expenditures, compared to countries in Africa that spend around $10. While this opens the door to a critique on efficiency, it’s far more indicative of the disparities in health resources.</p>
<p>Less than 20 percent of the world’s population lives in some of the most developed and economically high-functioning countries, including the United States – and nearly 90 percent of the world’s total financial resources are devoted to the citizens of these nations. And yet, low-income countries bear <a href="http://www.who.int/healthinfo/global_burden_disease/GlobalCOD_method_2000_2015.pdf?ua=1">the majority of the world’s infectious disease burden</a>. In short, the rest of the world does not suffer the same diseases the United States does, and Americans are doing little to nothing about it.</p>
<p>At first glance, this is not so surprising. As a whole, the world suffers – but how many neglected tropical diseases currently penetrate American borders?</p>
<p>Some experts predict that eliminating or controlling the neglected tropical diseases in sub-Saharan Africa alone, which shoulders over 40 percent of the global burden of neglected tropical diseases, could save the world <a href="http://www.end.org/docs/default-source/default-document-library/erasmus-ntd-data-set_may-2016.pdf?sfvrsn=2">$52 billion and over 100 million years of life</a> otherwise lost to disease.</p>
<p>Conversely, some global health experts estimate that for every dollar spent on neglected tropical disease control, we <a href="http://www.end.org/docs/default-source/default-document-library/end-fund-ntd-fact-sheet_may-2016.pdf?sfvrsn=2">get back over $50</a> in increased economic productivity. By increasing awareness and funding of neglected tropical disease eradication, the United States will be making one of the best global investments possible. The rest of the world has waited long enough.</p><img src="https://counter.theconversation.com/content/84177/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katherine J. Wu does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A cure for many tropical diseases was discovered 30 years ago this month. The drug is donated by its manufacturer. Why are we still dealing with neglected tropical diseases?Katherine J. Wu, Ph.D. Candidate in Microbiology, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/808982017-07-16T10:20:56Z2017-07-16T10:20:56ZAfrican academics set out what Dr Tedros needs in his toolbox to tackle health ills<figure><img src="https://images.theconversation.com/files/178244/original/file-20170714-3488-1i1rcen.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">New World Health Organisation Director-General De Tedros Adhanom Ghebreyesus. </span> <span class="attribution"><span class="source">Reuters/Denis Balibouse</span></span></figcaption></figure><p>Africa has the highest burden of HIV/Aids and malaria with escalating rates of non-communicable diseases. How will the World Health Organisation’s Director-General Dr Tedros Ghebreyesus deal with the mounting challenges? The Conversation Africa asked academics across the continent what impact his appointment will have, and for advice on what he needs to do, to manage the challenges.</p>
<hr>
<p><strong>What is the significance of his appointment?</strong></p>
<p><em><strong>Dr Thumbi Mwangi, Washington State University, Kenya Medical Research Institute:</strong></em> It’s two fold. As an African he has been closely involved in the battle against <a href="https://parasitesandvectors.biomedcentral.com/articles/10.1186/1756-3305-5-240">neglected tropical diseases</a> like rabies, trachoma, guinea worm and others which affect <a href="http://www.who.int/mediacentre/news/releases/2017/ntd-report/en/">1 billion</a> people. He was <a href="http://www.reuters.com/article/us-health-who-idUSKBN18J278">health minister</a> in Ethiopia where neglected tropical diseases are common. He needs no lectures on why the WHO must remain at the forefront of fighting them.</p>
<p>Secondly, his ownership of the agenda as set out in his campaign <a href="http://www.drtedros.com/">manifesto</a> – to work towards “a world where everyone can lead healthy and productive lives, regardless of where they are or where they live” – should be seen and felt.</p>
<p><em><strong>Dr Andrew Githeko, Kenya Medical Research Institute:</strong></em> Dr Tedros
brings a <a href="http://www.who.int/dg/tedros/en/">wealth of experience</a> and skills in governance, diplomacy, advocacy and resource mobilisation.</p>
<p>His efforts as <a href="https://www.usaid.gov/news-information/frontlines/child-survival-ethiopia-edition/interview-dr-tedros-adhanom-ghebreyesus">health minister</a> in Ethiopia produced measurable and significant outcomes. He’s familiar with addressing infectious diseases like malaria as well as non infectious diseases.</p>
<p>He also led <a href="http://www.drtedros.com/publications/">research</a> into effective ways of controlling malaria and greatly improved the ways in which it’s prevented and controlled.</p>
<p>On top of this, he played a momentous role in bilateral and multilateral malaria initiatives including those supported by <a href="http://www.rollbackmalaria.org/">The Roll Back Malaria Partnership</a> and the <a href="https://www.theglobalfund.org/en/">Global Fund</a>. </p>
<p>As a researcher he will be sympathetic to the plight of researchers from developing countries.</p>
<p><em><strong>Dr Karen Daniels, South African Medical Research Council:</strong></em> Dr Tedros comes from The Horn of Africa which remains a politically fragile setting, vulnerable to the impact of conflict and natural disasters. What this means is that he’s been in the health care trenches, like many of us who live and work in health settings across the continent. This is precisely where it’s been shown that Africa can find African solutions to African problems. </p>
<p>A leader like this is needed at the helm of the WHO. Dr Tedros will understand that Africans can be included in partnerships rather than dominated in the quest to find solutions to the unique challenges that the continent faces. </p>
<p>From an African health policy and systems research perspective, there are many reasons to laud his appointment. He brings the combined perspective of having been a researcher, a health systems manager, minister of health for Ethiopia, and a policymaker. </p>
<p><em><strong>Professor Bob Mash, Stellenbosch University:</strong></em> Dr Tedros is the first WHO director-general to have firsthand knowledge of the challenges facing African countries and health systems. One of his priority areas is “health for all” and providing universal health coverage. This implies a commitment to the strengthening of health systems, particularly primary health care. </p>
<p>This should stimulate research on disease orientated programmes as well as cross cutting systematic issues like the primary care workforce, access to care, patient-centredness, community orientated primary care as well as continuity, coordination and comprehensiveness of care. </p>
<p>But his experience in Ethiopia may not have sensitised him as much to the global problem of non-communicable diseases that’s also becoming a problem on the African continent. One of my concerns is whether he will give sufficient attention to the epidemic of diseases such as hypertension and diabetes.</p>
<p><strong>What are three biggest challenges facing him? What should he tackle first?</strong></p>
<p><em><strong>Dr Mwangi, Washington State University, Kenya Medical Research Institute :</strong></em> The WHO has faced <a href="http://www.who.int/topics/financial_crisis/financialcrisis_report_200902.pdf">financial constraints</a> addressing global health challenges including outbreaks of emerging infections.</p>
<p>Countries that are adversely affected by <a href="http://www.who.int/neglected_diseases/diseases/en/">neglected tropical diseases</a> need his voice and the diplomacy of his organisation to keep these diseases high on the global agenda, as well as top priority in affected countries.</p>
<p>Dr Tedros needs to make three focused commitments while he’s at the helm. </p>
<p>The first is domestic financing: for a long time countries affected by neglected tropical diseases have relied mainly on external funds. He needs to urge them to commit their own budgets to these diseases. Domestic budgets can help significantly. We need relatively low cost solutions such as drug tablets that are out of patent, improved hygiene for the affected populations and existence of effective vaccines.</p>
<p>Dr Tedros should also encourage partners to keep their commitments.</p>
<p>Secondly, there should be a deliberate effort to integrate the detection, surveillance and treatment of these diseases into the health system. Countries stand a much better chance of reducing and finally eliminating neglected tropical diseases if the interventions are embedded in primary health care systems.</p>
<p>The <a href="http://apps.who.int/iris/bitstream/10665/43485/1/9789241594301_eng.pdf">One Health</a> concept that brings together the human and animal health perspectives should also be practised. Dr Tedros supports this <a href="http://www.sciencedirect.com/science/article/pii/S0140673610614651">concept</a>. His challenge will be how to break the current silos in individual sectors. </p>
<p>Innovations offer important toolkits to consider. This includes <a href="http://www.sciencedirect.com/science/article/pii/S0277953613006485">mobile phones</a> to diagnose and report diseases as well as attempts such as use of <a href="http://www.gavi.org/library/news/gavi-features/2016/rwanda-launches-world-s-first-national-drone-delivery-service-powered-by-zipline/">drones</a> to supply emergency medical care and use of <a href="https://news.wsu.edu/2016/10/24/rabies-vaccine-effective-warm/">rabies vaccine</a> that needs little refrigeration that can be delivered by community health workers.</p>
<p><em><strong>Dr Githeko, Kenya Medical Research Institute:</strong></em> When it comes to malaria his greatest challenge will be to sustain – and increase – resources to the various control programmes, particularly in sub Saharan Africa.</p>
<p><a href="http://www.who.int/malaria/areas/drug_resistance/overview/en/">Resistance</a> to malaria medicines is a global health threat. Dr Tedros should support malaria endemic countries to expand and accelerate national efforts to control and eliminate malaria.</p>
<p>The WHO should urge member states to improve the training of health workers so that they closely follow the protocols in the treatment and management of malaria. This will save more lives.</p>
<p>The infrastructure in health facilities should also be improved to test for malaria, and to treat it more efficiently. This can only be achieved through concerted efforts and commitments by WHO member states.</p>
<p>The research wings in various countries need to be supported to encourage novel research of drug and insecticide resistance. Support for research will be critical to address scientific, behavioural, and socioeconomic factors that affect malaria control.</p>
<p><em><strong>Dr Karen Daniels, South African Medical Research Council:</strong></em> There is a vicious cycle in which the burden of increased communicable and non-communicable diseases weaken health systems. Dr Tedros has the challenge of strengthening these systems, something he’s already committed to. </p>
<p>This has to be supported by sound health policy and systems research, to help find solutions to the continent’s health challenges. But better home grown solutions need more investment in national and Pan African centres of excellence. Dr Tedros could help by enabling greater WHO investment in health policy and systems research. These centres of excellence should be founded on close collaboration between researchers, health systems managers, health systems policymakers, as well as communities and civil society organisations. </p>
<p>Centres of excellence could facilitate closer collaboration between health policy, the research community and the WHO. This could help ensure that research is more closely aligned to the real challenges faced in our own countries. We will hopefully begin to reduce the “know-do gap” where research evidence exists, but isn’t taken up in implementation.</p>
<p><em><strong>Professor Mash, Stellenbosch University:</strong></em> One of his greatest challenges will be strengthening health systems at primary health care level. Governments need to be convinced to invest in primary health care as the hub and not the marginalised periphery where poorly trained and low level health care workers offer fragmented and poor quality care. Strong multidisciplinary teams should include a family physician.</p>
<p>Strong primary health care is a prerequisite for providing universal health coverage. Ideally this should be through a national health insurance or systems that – at the very least – don’t impoverish people or increase inequality.</p><img src="https://counter.theconversation.com/content/80898/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bob Mash receives funding from European Union to strengthen primary health care through primary care doctors and family physicians in South Africa.</span></em></p><p class="fine-print"><em><span>Karen Daniels is a Specialist Scientist for the Health Systems Research Unit of the South African Medical Research Council, and a member of the Health Systems Global Board. The opinions expressed here are based on her own independent thoughts and views.</span></em></p><p class="fine-print"><em><span>Thumbi Mwangi receives funding from Wellcome Trust, GAVI and World Health Organisation.</span></em></p><p class="fine-print"><em><span>Andrew Githeko does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>How will the World Health Organisation’s Director-General Dr Tedros Ghebreyesus deal with the mounting challenges? Africa’s academics have some tips.Andrew Githeko, Chief Research Officer, Kenya Medical Research InstituteBob Mash, Division of Family Medicine and Primary Care, Stellenbosch UniversityKaren Daniels, Specialist Scientist, Health Systems Research Unit, South African Medical Research CouncilThumbi Mwangi, Clinical assistant professor, Washington State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/713372017-02-06T19:15:50Z2017-02-06T19:15:50ZWhy the housing shortage exacerbates scabies in Indigenous communities<p>Scabies is a disease of antiquity, one of the scourges of those on the First Fleet but no longer known for most in Australian society. However, in the far remote Northern Territory, scabies infection remains endemic, and in some regions <a href="https://www.ncbi.nlm.nih.gov/pubmed/22070701">almost 70%</a> of Aboriginal children in remote areas had been infected within their first year of life.</p>
<p>Recent research in the <a href="https://www.mja.com.au/">Medical Journal of Australia</a> estimates that as many as one in 100 Aboriginal people in the Katherine region suffers from the highly virulent infection, crusted scabies, and links this with homelessness and remote living. A person with crusted scabies has the potential to infect hundreds if not thousands of others, and these cases drive ongoing extreme rates of infection in Aboriginal communities. </p>
<h2>What is scabies?</h2>
<p><a href="https://theconversation.com/scabies-a-neglected-parasitic-disease-we-already-know-how-to-treat-68147">Scabies</a> is a tiny mite the size of a pin head. When a person is initially infected (usually by only a dozen or so of the mites), it takes a few weeks for the immune system to recognise these unwanted arthropods burrowing through the dermis (the inner layer of skin). </p>
<p>When the immune system kicks in, the extreme itch begins and the body fights back against the bugs. If a person’s immune system is working properly, the population of bugs on an individual never expands beyond a few dozen at most, and they remain relatively noncontagious. But the scratch marks from the cursed itch often cause streptococcal infections that can result in other conditions such as <a href="https://theconversation.com/why-are-aboriginal-children-still-dying-from-rheumatic-heart-disease-63814">rheumatic heart disease</a>.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/152816/original/image-20170116-16922-1q7pxqx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/152816/original/image-20170116-16922-1q7pxqx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/152816/original/image-20170116-16922-1q7pxqx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/152816/original/image-20170116-16922-1q7pxqx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/152816/original/image-20170116-16922-1q7pxqx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/152816/original/image-20170116-16922-1q7pxqx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/152816/original/image-20170116-16922-1q7pxqx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/152816/original/image-20170116-16922-1q7pxqx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Crusted scabies infection of the hand.</span>
<span class="attribution"><span class="source">Bart Currie, Menzies School of Health Research.</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>However, if an infected individual’s immune system does not work, the bugs breed prolifically in the skin and the numbers reach the many tens of thousands. At the same time, they erode the skin, making it “crusted” – a term that only makes sense when you see the crusts that constantly shed off, landing wherever the person moves. </p>
<p>These crusts are highly contagious, and thus the person infects everyone who crosses their path - on bus seats, in the cinema, on mattresses, lounge chairs and footpaths.</p>
<h2>What has scabies got to do with housing?</h2>
<p>In the Katherine region, it’s estimated as many as one in four Aboriginal people is homeless, either literally (living as fringe-dwellers in makeshift riverside camps), or technically (the <a href="http://abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4922.0Main+Features12012?OpenDocument">ABS defines homelessness</a> as a situation in which a person has no alternatives to their current inadequate dwelling, has no tenure, and cannot control space for social relations).</p>
<p>As many Aboriginal people in Katherine can’t afford the private rental market, public housing is the only alternative. Currently in Katherine there is a five year wait, and to be on the wait list <a href="https://nt.gov.au/__data/assets/pdf_file/0020/202439/sf117-application-for-public-housing-form.pdf">a person needs to have a postal address</a> for the Department of Housing to communicate with them. Rules, regulations and bureaucracy around the wait list change all of the time. It is a challenge to ensure that a name stays on the wait list for the five years until a house is available. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/152817/original/image-20170116-16928-5ur5qk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/152817/original/image-20170116-16928-5ur5qk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/152817/original/image-20170116-16928-5ur5qk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=451&fit=crop&dpr=1 600w, https://images.theconversation.com/files/152817/original/image-20170116-16928-5ur5qk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=451&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/152817/original/image-20170116-16928-5ur5qk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=451&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/152817/original/image-20170116-16928-5ur5qk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=567&fit=crop&dpr=1 754w, https://images.theconversation.com/files/152817/original/image-20170116-16928-5ur5qk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=567&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/152817/original/image-20170116-16928-5ur5qk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=567&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Microscopic view of a small crust showing heavy infestation with scabies mites.</span>
<span class="attribution"><span class="source">Bart Currie, Menzies School of Health Research.</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Young people are forced to stay at home, even when they have children of their own. Many houses in the Katherine region have four generations under the one roof. The dream of starting a family and living in a house of their own is a distant prospect for many Aboriginal people living in Northern Australia.</p>
<p>Remote-living people have limited options to relocate to bigger centres like Katherine or Darwin without having to embrace homelessness for at least a temporary period. Many of these people’s temporary situations become permanent in bush and riverside fringe dwelling camps where there is no sanitation, running water or secure shelter.</p>
<p>Because most houses are overcrowded, visiting family members often stay in houses already on the brink of bursting. An uncle comes to town. Ashamed of his skin condition and not knowing what is causing the crusting, he hides his deformed and ugly skin under long sleeves and jeans. But the crusts drop to the floor. Everyone in the house is infected.</p>
<p>And if he is lucky enough to endure the gruelling hospital treatment to get rid of the scabies, he is likely to move back into circles of living where scabies rates are high, and the reason his immune system does not work will probably still be there. He will be reinfected within a week or so, and his infection will become crusted again within the next six months. </p>
<h2>What can be done?</h2>
<p>Crusted scabies was added to the list of notifiable diseases in the Northern Territory in 2016. This will ensure identified cases of crusted scabies will be treated in a systematic way that includes ensuring household contacts are followed up properly. </p>
<p>The Northern Territory Department of Health Centre for Disease Control is working closely with the philanthropic organisation <a href="http://onedisease.org/">One Disease</a>. They are learning from the strong successes this organisation has already achieved over the past five years in Arnhem Land, in an effort to replicate this success with other vulnerable populations in the NT.</p>
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<a href="https://images.theconversation.com/files/152819/original/image-20170116-16931-10b9jix.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/152819/original/image-20170116-16931-10b9jix.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/152819/original/image-20170116-16931-10b9jix.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=387&fit=crop&dpr=1 600w, https://images.theconversation.com/files/152819/original/image-20170116-16931-10b9jix.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=387&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/152819/original/image-20170116-16931-10b9jix.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=387&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/152819/original/image-20170116-16931-10b9jix.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=486&fit=crop&dpr=1 754w, https://images.theconversation.com/files/152819/original/image-20170116-16931-10b9jix.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=486&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/152819/original/image-20170116-16931-10b9jix.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=486&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A scabies mite.</span>
<span class="attribution"><span class="source">Bart Currie, Menzies School of Health Research.</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Australia is at the forefront of scabies research, and there are exciting developments in understanding how to tackle the challenge of scabies in areas like remote Northern Australia where great distances, tropical weather and mobile populations <a href="http://www.menzies.edu.au/page/Research/Indigenous_Health/Skin/Scabies/">create challenges</a> in eradicating the disease.</p>
<p>And the underlying problem of homelessness is far from solved. This fundamental inequality, with homelessness rates being <a href="http://www.abc.net.au/interactives/homeless/">31 times the national average</a> in regions like Katherine, has its roots in the process of colonisation and the earliest narratives of our nation’s psyche. </p>
<p>Aboriginal fringe dwellers like <a href="http://findingbennelong.com/perspectives-bennelong">Bennelong</a> still exist in Australia. Many Aboriginal people and their ancestors have never had a safe “home” since their society was ruptured by the arrival of the colonisers. In towns like Katherine, the concept of “home” for many people is still undergoing great transformation.</p>
<p>The problem of homelessness for remote Aboriginal people is arguably one of the strongest drivers of poor social and health outcomes. While homelessness may result in poor health outcomes, the fundamental solution to homelessness cannot be driven by the health care sector. Instead, more could be done by engagement between Aboriginal communities and local councils, architects, economists, social anthropologists, builders and plumbers. </p>
<p>Scabies, rheumatic heart disease, kidney disease, diabetes, and smoking all contribute to a life expectancy more than <a href="http://www.aihw.gov.au/deaths/life-expectancy/">ten years below the national average</a>. If we want to live in a country where Aboriginal people can expect to live as long as non-Aboriginal people, medical research can go only so far.</p><img src="https://counter.theconversation.com/content/71337/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Quilty does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Scabies was one of the scourges of those on the First Fleet, but no longer known for most in Australian society. However, in the far remote North, scabies infection is endemic.Simon Quilty, General and Acute Care Physician and Senior Lecturer, Flinders University, Katherine Hospital campus, Flinders UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/704182016-12-30T11:10:50Z2016-12-30T11:10:50ZA new approach for controlling intestinal worm infections could help millions of the world’s most vulnerable people<p><a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32123-7/fulltext">Expanding the control strategy</a> for intestinal worms to treating adults as well as children could improve the health of millions of people worldwide who are infected or reinfected by these parasites every year.</p>
<p>These intestinal worms – soil-transmitted helminths – are responsible for the most common parasitic disease of humans worldwide. A staggering <a href="https://parasitesandvectors.biomedcentral.com/articles/10.1186/1756-3305-7-37">1.45 billion people</a> – that’s nearly a fifth of the global population – are affected and at risk of the long-term consequences of this largely preventable infection. </p>
<h2>Neglected diseases</h2>
<p>Soil-transmitted helminthiasis is one of 17 “<a href="http://www.who.int/neglected_diseases/en/">neglected tropical diseases</a>”, a grouping that also includes <a href="http://www.who.int/denguecontrol/en/">dengue and chikungunya</a>, <a href="http://www.who.int/rabies/en/">rabies</a>, and <a href="http://www.who.int/lep/en/">leprosy</a>. These infectious diseases largely affect the world’s most impoverished people, causing a <a href="http://thelancet.com/journals/lancet/article/PIIS0140-6736(16)31460-X/fulltext">high human and economic toll</a> through chronic disability. </p>
<p>As their name suggests, they have historically received little global interest or research funding <a href="http://sitn.hms.harvard.edu/flash/2010/ntds-diseases-of-the-bottom-billion/">when compared to the “big three” diseases</a> on the global health agenda: HIV/AIDS, tuberculosis and malaria.</p>
<p>The good news is that neglected tropical diseases have been rising to prominence since the <a href="http://unitingtocombatntds.org/resource/london-declaration">2012 London Declaration on Neglected Tropical Diseases</a>. This large public-private partnership is committed to eliminating or controlling ten preventable neglected tropical diseases by 2020, and has attracted substantial investment from <a href="http://unitingtocombatntds.org/endorsements">government and philanthropic sources</a>. </p>
<p>It’s also included unprecedented drug donations from large pharmaceutical companies to combat the five neglected tropical diseases that can be controlled or eliminated with medication: <a href="http://www.who.int/trachoma/en/">trachoma</a>, <a href="http://www.who.int/onchocerciasis/en/">onchocerciasis</a> (river blindness), <a href="http://www.who.int/lymphatic_filariasis/en/">lymphatic filariasis</a>, <a href="http://www.who.int/schistosomiasis/en/">schistosomiasis</a>, and <a href="http://www.who.int/intestinal_worms/en/">soil-transmitted helminthiasis</a>. </p>
<p>Soil-transmitted helminthiasis is by far the most prevalent of all 17 neglected tropical diseases. Transmitted through the accidental ingestion of worm eggs that are released in the faeces of people who are already infected, they thrive in areas with poor sanitation and hygiene, and are <a href="https://parasitesandvectors.biomedcentral.com/articles/10.1186/1756-3305-7-37">endemic across Africa, Southeast Asia, and the Pacific</a>. </p>
<p>Children suffer disproportionately from the consequences of these infections. Due to the nutrient malabsorption and chronic blood loss that infection causes, children with heavy worm infestations can suffer developmental setbacks and fail to reach their <a href="https://www.cambridge.org/core/journals/parasitology/article/div-classtitlemalnutrition-and-parasitic-helminth-infectionsdiv/7B648AE4E9EBC6C006AC39272FFA7BE7">full physical</a> and <a href="http://www.ajtmh.org/content/72/5/540.abstract?ijkey=9a58f7fef34546e6cbc6c052246779d441e96419&keytype2=tf_ipsecsha">intellectual capacity</a>. This perpetuates the cycle of poverty in which they and their families are entrenched. </p>
<p>As a result of frequent exposure to contaminated environments, over <a href="http://unitingtocombatntds.org/report/third-report-country-leadership-and-collaboration-ntds">876 million children</a> are currently at risk of infection from these intestinal worms.</p>
<h2>Current control efforts</h2>
<p>The key public health intervention for controlling soil-transmitted helminthiasis is the large-scale distribution of <a href="http://www.wormbook.org/chapters/www_anthelminticdrugs/anthelminticdrugs.html">anthelmintic medication</a> – often referred to as “deworming”. This must be repeated regularly as people don’t develop long-lasting immunity to intestinal worms, and can <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0001621">soon be reinfected</a> if their environment remains contaminated.</p>
<p>Children are the primary focus of global control efforts for intestinal worms because of the greater impact the disease has on them. <a href="http://www.who.int/neglected_diseases/resources/9789241503129/en/">World Health Organization guidelines</a> have focused predominantly on deworming school-aged children (five to 14-year-olds), with the goal of preventing complications associated with heavy infections. </p>
<p>Deworming through schools is an efficient and low-cost approach. The drugs are easy to administer and side effects are rare, so children can be treated by their teachers, <a href="http://www.sciencedirect.com/science/article/pii/S0001706X99000285">minimising the costs</a> of both infrastructure and personnel. </p>
<p>Between 2008 and 2013, the number of children treated for intestinal worms globally <a href="http://unitingtocombatntds.org/report/third-report-country-leadership-and-collaboration-ntds">nearly doubled</a>, and over half a billion children were <a href="http://apps.who.int/iris/bitstream/10665/250245/1/WER9139.pdf?ua=1">treated in 2015</a>. </p>
<p>This is astounding progress, and a testament to what can be achieved with concerted, collaborative effort. But it doesn’t prevent reinfection and relies on regularly re-administering medication. </p>
<h2>A better approach?</h2>
<p>The last few years years have seen burgeoning interest from researchers in the idea of <a href="http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(16)30535-7/fulltext">expanding soil-transmitted helminthiasis control programs</a> beyond school-based deworming. </p>
<p>This interest has centred mainly on the idea that treating all community members, rather than only children, could lead, over time, to “<a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0003897">transmission interruption</a>” – elimination of all worms would mean regular deworming is no longer required. This suggestion has been supported by several <a href="http://rstb.royalsocietypublishing.org/content/369/1645/20130435.short">mathematical modelling</a> studies. </p>
<p><a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32123-7/fulltext">Research that my colleagues and I recently published</a> shows expanded deworming programs may also have direct and, more significantly, immediate benefits for children. </p>
<p>We undertook an analysis of the results from dozens of previous studies of intestinal worm control programs, delivered either to children alone or to whole communities. What we found was that when whole communities are given deworming medication, children are less likely to be reinfected, than when only children are treated in the first instance.</p>
<p>The findings make sense. Expanded deworming programs will reduce the number of people excreting worm eggs into the environment, thereby reducing exposure and infection. But until now, robust evidence to support this idea has been lacking. </p>
<p>We can now be confident that expanding control programs to whole communities will result in children having fewer infections. Although current child-focused efforts are lowering the number of infections and reducing complications, the growing body of evidence for expanding deworming compels us to revisit our current approach.</p>
<p>But community-wide treatment is far from a quick fix. It would require a significant increase in drug donations and other resources. And complicating factors, such as the increased potential for drug resistance, need to be carefully considered. But, as a global community, we must ensure that we are doing our best to promote the health and well-being of vulnerable populations. </p>
<p>Neglected tropical diseases afflict some of the most world’s most vulnerable people, and we must maintain the momentum of recent times in controlling these diseases. There’s a growing body of evidence that shows we could be doing more for the close to billion children at risk of intestinal worms. We simply cannot afford to ignore it.</p><img src="https://counter.theconversation.com/content/70418/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susana Vaz Nery has received funding from the Bill and Melinda Gates Foundation. </span></em></p><p class="fine-print"><em><span>Naomi Clarke does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There’s a growing body of evidence that shows we could be doing more for the close to billion children at risk of intestinal worms. We simply cannot afford to ignore it.Naomi Clarke, PhD candidate in Global Health, Australian National UniversitySusana Vaz Nery, Research Fellow - Global Health, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/681472016-11-14T19:09:55Z2016-11-14T19:09:55ZScabies: a neglected parasitic disease we already know how to treat<figure><img src="https://images.theconversation.com/files/145497/original/image-20161110-25070-1jo9pkd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Children living in tropical countries and in poverty often have high rates of infection with the scabies mite. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/unicefethiopia/27422673482/in/photolist-fF6fH7-fNi2S3-bpfAWr-5cxNdy-EjhEP3-HMfhX3-H1FrRd-HjT2KB-HjT8wB-HjT1oD-H19RFJ-HMfnrd-HVZ9kT-Ho2xW9-HqYEsn-H1FqN1-Gvq5N9-HqYF6M-HjT9tr-HhvVqN-H1FsFu">UNICEF Ethiopia/flickr </a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>Mites living in your skin are just the start of the problems that come with having scabies. </p>
<p>The highly infectious parasitic condition is linked with extreme itchiness, bacterial infections and kidney damage, plus debilitating social and economic consequences. </p>
<p>But we’re not addressing the problem. Although a drug of known safety and efficacy is available, scabies still affects more than 100 million people across the world who can’t break free of illness and reinfection cycles. </p>
<p>This week the <a href="http://www.ntdsupport.org/cor-ntd">Coalition for Operational Research on Neglected Tropical Diseases</a> and the <a href="http://www.controlscabies.org/news/5th-global-scabies-meeting/">International Alliance for the Control of Scabies</a> met to refocus efforts to reduce the impact of scabies across the world. </p>
<h2>Scabies: mites living in your skin</h2>
<p>Scabies is a skin disease caused by infestation with a highly infectious microscopic mite, <em>Sarcoptes scabiei</em>. Less than 1mm in size, the mite burrows into the skin, and leads to intense itching and visible sores. Sleep interruption and social stigmatisation result. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=445&fit=crop&dpr=1 600w, https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=445&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=445&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=560&fit=crop&dpr=1 754w, https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=560&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=560&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Less than 1mm long, the scabies mite burrows into the skin and creates intense itching.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/136941790@N03/22635992060/in/photolist-ffoG6C-fF6fH7-nEcjSk-oCDASr-nWoJAB-fNi2S3-bpfAWr-9Mm8AY-9MiicF-b9xbdZ-7fwayX-9MihZt-sruAYQ-6ikkq6-6hnMCL-6h4Ndc-cog1R7-cofudy-cofunj-bVvVoz-coigm7-cogyos-cQg3Ub-cU7Zad-cQSvJu-AugnPb-71RABC-dbMybJ-vmPTY9">laboratorio diagnostica ancona IZSUM/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Intense scratching triggered by scabies infection also allows bacteria (<em>Streptococcus pyogenes</em> and <em>Staphylococcus aureus</em>) to become established in the skin. </p>
<p>Scabies is usually treated with a topical cream: in Australia, permethrin is the common choice. </p>
<p>In addition to the infected person, household contacts are often infested with scabies, and so the whole household should be treated at once. However, uptake of treatment in household members is often very low and so re-infestation is common. In settings where the prevalence is high, it is very difficult to avoid re-infestation from other community members, especially among children. </p>
<h2>Scabies is a huge global problem</h2>
<p>Scabies affects more than 100 million people worldwide. It is especially common in the Pacific region: in Fiji, half of all primary school aged children have scabies, as well as one in five adults. Up to one third of people living in remote Australian Indigenous communities are infected. </p>
<p>While scabies itself is a distressing health issue, the greatest impacts occur as a result of associated bacterial infections. <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0002167">Scabies commonly leads</a> to impetigo (skin sores), and severe skin and soft tissue infections and sometimes even invasive bacterial infection and <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0002167">life-threatening toxic shock syndrome</a> can follow. </p>
<p>The body’s immune response to <em>Streptococcus pyogenes</em> bacteria can cause <a href="http://www.kidshealth.org.nz/post-streptococcal-glomerulonephritis-psgn">kidney damage</a> and possibly <a href="https://www.ncbi.nlm.nih.gov/pubmed/22327467">rheumatic heart disease</a>. </p>
<p>Scabies is therefore a cause of considerable illness and is also linked to some deaths.</p>
<h2>Scabies qualifies as a Neglected Tropical Disease</h2>
<p><a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0002167">Efforts are increasing</a> for scabies to be added to a list of conditions classified as Neglected Tropical Diseases. </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/books/NBK62521/">Neglected Tropical Disease global movement</a> began in the early 2000s in response to the <a href="http://www.un.org/millenniumgoals/">Millennium Development Goals</a>. A Department of Neglected Tropical Diseases was soon <a href="http://www.who.int/neglected_diseases/en/">established at the World Health Organisation</a> (WHO) to coordinate and support policies and strategies specifically for the control of neglected tropical diseases.</p>
<p><a href="http://www.who.int/neglected_diseases/diseases/summary/en/">Seventeen conditions</a> currently make up the Neglected Tropical Diseases list, including <a href="http://www.who.int/onchocerciasis/en/">onchocerciasis</a> (river blindness), <a href="http://www.who.int/lymphatic_filariasis/en/">lymphatic filariasis</a> (parasitic worms in the lymph system), bacterial eye infections known as <a href="http://www.who.int/trachoma/en/">blinding trachoma</a>, <a href="http://www.who.int/schistosomiasis/en/">schistosomiasis</a> (blood parasites acquired through water) and <a href="http://www.who.int/intestinal_worms/en/">soil transmitted intestinal worms</a>. </p>
<p>Although not currently on the list, scabies has many features that warrant its inclusion. These include its high prevalence in low to middle income countries and in disadvantaged communities, the social stigma it causes, the chronic morbidity associated with the disease and known success of mass drug administration as a control strategy.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The skin infection impetigo develops when bacteria colonise skin damaged through intense scratching in scabies.</span>
<span class="attribution"><span class="source">Andrew Steer</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Mass drug administration for disease control</h2>
<p><a href="http://www.who.int/neglected_diseases/preventive_chemotherapy/en/">Mass drug administration</a> is the centrepiece of ambitious global plans to eliminate several major Neglected Tropical Diseases. More than 700 million people receive mass drug administration every year through large regional and global programs supported by the World Health Organization and partners. At the community level, drugs are delivered by specially trained distribution teams. </p>
<p>The oral drug <a href="http://www.merck.com/product/usa/pi_circulars/s/stromectol/stromectol_pi.pdf">ivermectin</a> is the most frequently delivered agent, used in highly successful programs for control of <a href="http://www.who.int/lymphatic_filariasis/elimination-programme/en/">lymphatic filariasis</a> and <a href="http://www.who.int/onchocerciasis/control/en/">onchocerciasis</a>. </p>
<p>The <a href="https://www.nobelprize.org/nobel_prizes/medicine/laureates/2015/press.html">2015 Nobel Prize for Medicine</a> was awarded to William Campbell and Satoshi Omura for their discovery of ivermectin and in recognition of the contribution of the drug in improving global public health. </p>
<h2>A new approach for scabies eradication</h2>
<p>Could mass drug administration for scabies work? Mass permethrin treatment for scabies was successful in <a href="https://www.ncbi.nlm.nih.gov/pubmed/1673175">Panama</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/11700814">Australia</a>. However, this cream is not ideal for use in public health initiatives because it is messy to apply and adherence can be low, and because the tubes are bulky and difficult to transport. </p>
<p>But scabies can also be killed effectively with ivermectin, an oral medication that comes in tablet form. </p>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pubmed/26650152">clinical trial conducted in a Fijian community</a> found a single round of ivermectin mass drug administration was able to virtually eliminate scabies: prevalence was reduced from 32% to less than 2%. This reduction in scabies was associated with a 67% drop in the prevalence of scabies-linked bacterial impetigo. </p>
<p>These results provide robust initial evidence to encourage investigation of ivermectin based mass drug administration as a means to control scabies in highly endemic populations on a larger scale. The trial further strengthens the claim for scabies to be considered as a WHO-listed neglected tropical disease. </p>
<h2>Let’s get rid of scabies</h2>
<p>There are several crucial elements that will lead to successful control of scabies and the alleviation of suffering for those afflicted by the disease. Integration with programs already in place for other neglected tropical diseases (especially those that use ivermectin mass drug administration), recognition and support by WHO, and strong advocacy are essential. </p>
<p>The <a href="http://www.controlscabies.org/">International Alliance for the Control of Scabies</a> was formed in 2012 and is the key global advocacy body for scabies. The Alliance is a network of professionals, including clinicians from high-prevalence areas, public health physicians, policy makers, and researchers, all of whom are committed to the control of human scabies infestation, and to promoting the health and well-being of all those living in affected communities. </p>
<p>Further research into the effect of ivermectin based mass drug administration on the severe bacterial complications of scabies is warranted. </p>
<p>Also, operational research into acceptability and cost effectiveness of mass drug administration will have an impact through strengthening the case for placing scabies alongside other neglected tropical diseases that are targeted for global elimination.</p><img src="https://counter.theconversation.com/content/68147/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Steer receives funding from the National Health and Medical Research Council of Australia and the National Heart Foundation of Australia. </span></em></p>Although a drug of known safety and efficacy is available, scabies still affects more than 100 million people across the world.Andrew Steer, Group Leader, Murdoch Childrens Research Institute. Associate Professor, Department of Paediatrics, University of Melbourne. Paediatric Infectious Diseases Physician, Royal Children's Hospital, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/565222016-04-19T04:31:54Z2016-04-19T04:31:54ZBuruli ulcer: Africa’s neglected but third most common mycobacterial disease<figure><img src="https://images.theconversation.com/files/119123/original/image-20160418-1291-10uijhh.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Buruli ulcer occurs mainly in areas close to stagnant water. Children under the age of 15 are often worst affected.</span> <span class="attribution"><span class="source">Supplied</span></span></figcaption></figure><p>Buruli ulcer is a skin infection that kills the cells and tissue in an affected area and creates ulcers on the skin. It is caused by a bacteria and is the <a href="http://www.uptodate.com/contents/buruli-ulcer-mycobacterium-ulcerans-infection">third most common</a> bacterial disease after TB and leprosy. </p>
<p>The disease was first reported in the 19th century by British physician <a href="http://www.allcountries.org/health/buruli_ulcer_disease.html">Sir Albert Cook</a>. But it was only in <a href="http://www.who.int/buruli/gbui/en/">1998</a> that the World Health Organisation started to pay attention, addressing it as a neglected tropical disease.</p>
<p>But more than 150 years after buruli ulcer was discovered, scientists still haven’t figured out how the mycobacterium that causes the disease is transmitted. There is still no cure or vaccine. The only way to control it is to detect the infection early and treat it with antibiotics. </p>
<p>The disease also has social consequences. Buruli manifests as large skin ulcers. These are unsightly and people who develop them are often <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0003303">stigmatised</a>. In areas where the disease is endemic on the continent there is also a belief that it is caused by <a href="http://www.examiner.com/article/health-authorities-try-to-convince-villagers-that-buruli-ulcer-is-not-the-result-of-witchcraft">“witchcraft”</a> or “allogens” (immigrants).</p>
<h2>A disease of the tropics</h2>
<p>Buruli ulcer is largely endemic in the tropics and has been reported in more than 30 countries in Africa, South America and Asia, as well as in Australia. In <a href="http://www.who.int/mediacentre/factsheets/fs199/en/">Africa</a>, the worst-hit countries are concentrated in the west and centre. These include Côte d’Ivoire, Ghana, Benin and Cameroon. </p>
<p>Of the 33 globally affected countries, 15 are found in Africa. Between 1978 and 1999, up to 22% of people living in communities where the disease was endemic were affected. In this period Côte d’Ivoire reported 15,000 new cases. But at the last World Health Organisation <a href="http://apps.who.int/iris/bitstream/10665/112669/1/WHO_HTM_NTD_IDM_2014.2_eng.pdf?ua=1&ua=1">buruli ulcer meeting</a>, there was a significant decline in most <a href="http://www.who.int/mediacentre/factsheets/fs199/en/">endemic countries</a>.</p>
<p>The disease is most prevalent in impoverished rural communities. Children under the age of 15 are the worst affected but there is no gender specificity. It often starts as an itchy nodule or papule on the skin. This develops into a massive skin ulcer if left untreated. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/119129/original/image-20160418-1263-u5k0cy.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/119129/original/image-20160418-1263-u5k0cy.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=544&fit=crop&dpr=1 600w, https://images.theconversation.com/files/119129/original/image-20160418-1263-u5k0cy.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=544&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/119129/original/image-20160418-1263-u5k0cy.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=544&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/119129/original/image-20160418-1263-u5k0cy.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=684&fit=crop&dpr=1 754w, https://images.theconversation.com/files/119129/original/image-20160418-1263-u5k0cy.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=684&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/119129/original/image-20160418-1263-u5k0cy.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=684&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A Ghanaian boy with a buruli ulcer on his arm.</span>
<span class="attribution"><span class="source">Supplied</span></span>
</figcaption>
</figure>
<p>This is followed by complications that can include muscle contractions, limbs becoming deformed and, in extreme cases, needing to be amputated, as well as organ failure. In some cases the disease is fatal. In a few cases it can lead to the development of <a href="http://www.medicinenet.com/osteomyelitis/article.htm">bone infections</a> or tetanus, or begin haemorrhaging, with patient death as a result. </p>
<p>The ulcers are not painful, which often leads to late diagnosis. This is largely due to the <a href="http://www.sciencedirect.com/science/article/pii/S0002944010621414">nerve cells</a> around the lesions dying.</p>
<h2>Unknown transmission mode</h2>
<p>Identifying the transmission mode of a disease is important because it helps control and possibly stop the disease spreading. But <a href="http://onlinelibrary.wiley.com/doi/10.1890/1540-9295(2005)003%5b0323:UAEDAW%5d2.0.CO%3b2/abstract">studies</a> have unsuccessfully tried to solve the puzzle of the buruli ulcer’s transmission. </p>
<p>What is <a href="http://aem.asm.org/content/68/9/4623.short">known</a> in laboratory studies is that the bacteria has to be introduced through broken skin, an injection or a deep cut with an object that carries the bacteria. </p>
<p>The disease occurs mainly in areas close to stagnant water and is rarely found in arid areas. As a result, research has focused on trying to find a relationship between humans and the organisms found in the aquatic environment. </p>
<p>Researchers have not been able to directly culture the bacteria from the environment because it grows slowly. It takes at least six months to form colonies of the bacteria in pure culture but these are often contaminated by other faster-growing bacteria.</p>
<p>They have taken two main approaches: detecting the bacteria’s DNA in aquatic organisms and in water in endemic regions; and looking at the genetic makeup of the bacteria. </p>
<p>There are challenges in mapping the baterium’s DNA in the environment. Various plants, insects, types of soil, water biofilm and waste have tested positive for the bacteria’s DNA. This led researchers to believe that the disease could be transmitted through <a href="http://www.sciencedirect.com/science/article/pii/S0738081X08002010">insect vectors</a>. But these theories have been complicated by the fact that the DNA is also found in snakes, possums, koalas and other small mammals. This makes it difficult to pinpoint one organism as the reservoir for the disease. </p>
<p>Trying to understand the disease through its genetic makeup is also challenging.
Research shows that the bacteria is <a href="http://genome.cshlp.org/content/17/2/192.short">constantly evolving</a>, which makes it difficult to understand how to tackle it. </p>
<p>To solve both these challenges, researchers are using multi-disciplinary approaches to establish the bacteria’s actual environmental reservoir or host. This involves studying how the genome evolves in relation to other environmental mycobacteria that are unable to reproduce outside their host.</p>
<h2>Diagnosis and treatment is limited</h2>
<p>There are also no simple tools to diagnose buruli ulcer that can be used easily in rural areas where the infection exists. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/119133/original/image-20160418-1273-1tuov33.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/119133/original/image-20160418-1273-1tuov33.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=477&fit=crop&dpr=1 600w, https://images.theconversation.com/files/119133/original/image-20160418-1273-1tuov33.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=477&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/119133/original/image-20160418-1273-1tuov33.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=477&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/119133/original/image-20160418-1273-1tuov33.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=600&fit=crop&dpr=1 754w, https://images.theconversation.com/files/119133/original/image-20160418-1273-1tuov33.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=600&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/119133/original/image-20160418-1273-1tuov33.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=600&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Swabsticks need to be tested for buruli ulcer to be diagnosed.</span>
<span class="attribution"><span class="source">Supplied</span></span>
</figcaption>
</figure>
<p>Doctors still rely on century old microscope and laboratory techniques for diagnosis. Swabs or tissue are taken from the cut, fixed on slides and stained to identify the bacteria. Modern techniques used to diagnose the disease involve amplifying genes to detect the bacteria. </p>
<p>Until 2006 buruli ulcers were treated by cutting them out surgically. But in the past ten years antibiotic chemotherapy using anti-TB drugs has been used with remarkable success in early lesions and also in conjunction with wound healing post-surgery.</p>
<p>Scientists and researchers are still developing urgently needed new anti-mycobacterial drugs. They are <a href="http://www.sciencedirect.com/science/article/pii/S037887411500433X">investigating</a> the viability of various resources, including fungal and plant-derived biologically active compounds that may stop the bacteria from growing during infection. But their efforts are hampered by the slow-growing rate of the bacteria.</p>
<h2>Filling the gaps</h2>
<p>Given that there is a great deal that’s not known about the disease, research is targeting vaccine development, how the disease emerges and is transmitted, early detection and diagnosis, and effective control strategies. These are the priority research areas directed by the World Health Organisation.</p>
<p>In addition, health education campaigns are being directed towards raising the public’s awareness about the disease and that medical treatment is preferable to traditional remedies. The World Health Organisation has produced cartoons to help children understand and accept the disease. The campaigns will go a long way to <a href="http://collectiveactionlab.com/sites/default/files/Stigma%20Reduction%20Strategies%20and%20Interventions.pdf">destigmatise</a> the disease, which is still marked by the stamp of shame. </p>
<p><em>Esenam Dzifa Buatsi, a biochemist and molecular biologist at the University of Ghana was integral in the writing of this article.</em></p><img src="https://counter.theconversation.com/content/56522/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lydia Mosi receives funding from World Bank, Wellcome Trust, Afrique One, University of Ghana Research Fund, TWAS, IFS. </span></em></p>A century and a half after buruli ulcer was discovered, the disease continues to mystify scientists.Lydia Mosi, Lecturer at the Department of Biochemistry, Cell and Molecular Biology, University of GhanaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/558802016-03-11T04:43:26Z2016-03-11T04:43:26ZWhy evolution must be at the centre of fighting parasitic infections<figure><img src="https://images.theconversation.com/files/114686/original/image-20160310-26256-1651dx5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A father reads to his son while sitting under a mosquito net. Mosquitoes have undergone evolutionary changes due to long-lasting insecticide-treated nets.</span> <span class="attribution"><span class="source">Georgina Goodwin and Vestergaard Frandsen</span></span></figcaption></figure><p><a href="http://www.who.int/neglected_diseases/diseases/en/">Neglected tropical diseases</a> and other parasitic infections such as malaria affect the lives of hundreds of millions of people across the tropics and sub-tropics. </p>
<p>Each year more than <a href="http://www.who.int/malaria/media/world_malaria_report_2013/en/">200 million cases</a> of malaria are recorded across the globe. In total, an estimated <a href="http://www.who.int/neglected_diseases/preventive_chemotherapy/PC_Update.pdf?ua=1">1.7 billion people</a> require treatment for neglected tropical diseases. These <a href="http://www.globalnetwork.org/neglected-tropical-diseases/fact-sheets">include</a> river blindness, snail fever, elephantiasis, sleeping sickness, among others.</p>
<p>Global efforts to <a href="https://theconversation.com/tropical-worms-they-infect-a-third-of-the-planet-so-why-arent-we-doing-more-46037">eliminate parasites</a> have only been partly effective because of limited resources. Proponents of the current strategies to eliminate malaria and neglected tropical disease parasites are right to say that we should use existing tools to save lives and prevent illness. But some parasites and vectors will have survived attack because they have evolved resistance.</p>
<h2>The effects of parasite evolution</h2>
<p>Parasite evolution occurs as a result of various types of pressure, such as [drug-pressure](http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(1500417-1/fulltext) on the parasites. This results in drug resistance. As a result of this process, there are selected strains of the parasite that have genetic mutations which resist efforts to be eliminated. </p>
<p>If a mutation confers a survival advantage to the organism it will start to <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1314981#t=article">spread</a> through that population. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/114681/original/image-20160310-26242-1fucga4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/114681/original/image-20160310-26242-1fucga4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=421&fit=crop&dpr=1 600w, https://images.theconversation.com/files/114681/original/image-20160310-26242-1fucga4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=421&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/114681/original/image-20160310-26242-1fucga4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=421&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/114681/original/image-20160310-26242-1fucga4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=529&fit=crop&dpr=1 754w, https://images.theconversation.com/files/114681/original/image-20160310-26242-1fucga4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=529&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/114681/original/image-20160310-26242-1fucga4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=529&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Chemicals that kill molluscs, known as molluscicides, can control Schistosoma infections. But using them may force an evolutionary change in the mollusc population to make them resistant to the chemical itself.</span>
<span class="attribution"><span class="source">Supplied</span></span>
</figcaption>
</figure>
<p>Over the past few decades, control programmes against malaria have been <a href="https://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-11-122">abandoned</a> due to drug or insecticide resistance. More recently, mosquitoes have undergone evolutionary changes due to long-lasting insecticide-treated nets. </p>
<p>Night-feeding mosquitoes have started to bite more often during the <a href="http://www.ncbi.nlm.nih.gov/pubmed/24678587">daytime</a>, and <a href="http://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-10-80">outdoors</a>. The results of this change are that both parasites and mosquitoes are more likely to survive and spread the mutations through the generations.</p>
<p>The only way to stop a mutation spreading is to eradicate the organism. So there is real danger that using tools such as bed-nets and <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3762885/">intermittent preventive therapy</a> will be insufficient to stop evolutionary mutations spreading. </p>
<h2>It’s all about the ecology</h2>
<p>The geographic distribution of parasitic infections including malaria and most neglected tropical diseases such as schistosomiasis is very patchy. <a href="http://www.ntdmap.org/">Maps</a> produced by epidemiologists and statisticians highlight this fact. There is variation in transmission not just at country or regional level, but quite often <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0002608">within communities</a>.</p>
<p>For many infections we know the reasons for this variation. For example, the <a href="http://www.cdc.gov/parasites/schistosomiasis/biology.html">life cycle of schistosoma</a> involves infections of humans and freshwater snails. The snails are sensitive to environmental conditions. <a href="http://parasitesandvectors.biomedcentral.com/articles/10.1186/s13071-014-0503-9">Experiments and observations</a> tell us that characteristics of the water are important factors in the population biology of the snails. </p>
<p>The information we get from ecological studies can be used to project what might happen in the future. For example, <a href="http://parasitesandvectors.biomedcentral.com/articles/10.1186/s13071-014-0617-0">recent research</a> suggests that global warming may even make some places become too hot for the snails to survive. We can infer from this work that climate change is likely to put a selection pressure on the snails. </p>
<p>Climate change is just one source of pressure on the life-cycle of parasitic infections. More broadly we must consider how environmental change might force evolution to occur among parasites, their vectors and their human or animal hosts. </p>
<p>Environmental change can be either man-made or due to natural processes. It includes interventions such as <a href="http://apps.who.int/iris/bitstream/10665/43545/1/9241547103_eng.pdf">mass-drug administration programmes</a>, bed-nets, insecticide, molluscicide and larvicide spraying, land-use change, extreme weather events, population increase and economic activities. </p>
<p>Even supplying low-energy light bulbs could have <a href="https://theconversation.com/theres-a-fly-in-the-ointment-of-solar-powered-led-lighting-49838">consequences</a>. This type of light bulb emits blue light, which is more attractive to flying insects including mosquitoes. So species of mosquito that evolve to prefer blue light may affect patterns of disease as result of programs such as <a href="https://www.gov.uk/government/news/energy-africa-campaign">Energy Africa</a>, which is promoting low-energy solutions for resource-poor people.</p>
<h2>A new approach</h2>
<p>Concerns have been raised about evolutionary consequences of current control efforts against <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)00417-1/fulltext">malaria</a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/24533260">some</a> neglected tropical diseases. But while a recent set of <a href="http://inthealth.oxfordjournals.org/content/8/suppl_1/i1.full">articles</a> about control of neglected tropical diseases has emphasised the need for operational research, there was no mention of evolution in any of its pages.</p>
<p>Can we stop evolution from occurring with only limited resources at our disposal? Probably not. </p>
<p>But we might slow it down by using current knowledge to ask the question: how must parasites and their vectors adapt to survive? This way of thinking is embedded into the discipline of <a href="http://www.pnas.org/content/107/suppl_1/1800.full">evolutionary medicine</a> – a subject taught in a few places, including my university, mainly not in terms of parasitic infections. </p>
<p>Evolutionary medicine offers a bridge between evolutionary theory and programme management. It can be used to do a “stress test” on a particular approach by identifying potential evolutionary pathways and presenting solutions that reduce the possibility of evolution occurring. Perhaps this information can be used to shape more effective interventions and look forward to a more sustainable and healthy future.</p>
<p>But by tackling the issue of how evolution may disrupt current efforts, we may have greater foresight and greater scope for sustainable control.</p><img src="https://counter.theconversation.com/content/55880/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Booth is affiliated with Durham University.</span></em></p>Although there have been global efforts to eliminate parasites, some parasites and vectors will have survived attack because they have evolved resistance.Mark Booth, Senior Lecturer in Epidemiology, Durham UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/523972015-12-16T16:37:43Z2015-12-16T16:37:43ZExplainer: what is the ‘flesh-eating’ disease that’s spreading across Syria?<p>As if years of war, terrorism and oppression weren’t harrowing enough for the people of Syria, the country <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4231133/">is experiencing</a> an epidemic of a so-called flesh-eating disease. Outbreaks of the disease, known as leishmaniasis, have been reported repeatedly over <a href="http://www.independent.co.uk/life-style/health-and-families/health-news/washington-warns-perfect-storm-of-conditions-leaves-isis-controlled-iraq-and-syria-vulnerable-to-9985686.html">the past year</a>. </p>
<p>More recently, the head of the Kurdish Red Crescent <a href="http://rudaw.net/english/middleeast/syria/02122015">was reported</a> to have said the problem was made worse by the actions of Islamic State leaving bodies to rot in the streets. But while leishmaniasis is a serious problem in Syria, this picture of a flesh-eating disease spread by terrorists isn’t entirely accurate.</p>
<h2>What is leishmaniasis?</h2>
<p>Leishmaniasis has actually been endemic to Syria for centuries and was once commonly known as “Aleppo evil”. This cutaneous (skin-affecting) form of the disease isn’t strictly “flesh eating”, although another form found in Brazil and some other parts of South America can be. It is caused by the <em>Leishmania</em> parasite, which is carried by sandflies. If you’re bitten by a fly, <a href="https://theconversation.com/six-human-parasites-you-definitely-dont-want-to-host-17332">the parasites</a> can enter your blood and invade the macrophage immune cells that normally kill bugs, causing causing horrible open sores close to the bite.</p>
<p>In other places, in particular India, a different form of the parasite spreads to the liver and spleen and causes death as those vital visceral organs break down. In the <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3820760/">Brazilian form</a>, the parasites cause macrophages to migrate to the mucosal surfaces around the mouth and nose. Here the immune system attacks the parasites but ends up causing substantial damage to surrounding tissue, eating away the flesh in these areas, leading to gross disfigurements.</p>
<p>Sandflies actually don’t eat rotting bodies on the street, they suck blood from living people, so the reports about Islamic State spreading the disease aren’t strictly true. However, the political events in Syria – including the rise of Islamic State – have caused the collapse of the country’s health systems, along with every other part of the social structure there. So inevitably, the disease <a href="http://www.ncbi.nlm.nih.gov/pubmed/25342106">has been spreading</a> more widely.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/106330/original/image-20151216-30072-5nlxde.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/106330/original/image-20151216-30072-5nlxde.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/106330/original/image-20151216-30072-5nlxde.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/106330/original/image-20151216-30072-5nlxde.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/106330/original/image-20151216-30072-5nlxde.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/106330/original/image-20151216-30072-5nlxde.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/106330/original/image-20151216-30072-5nlxde.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Leishmania parasite.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>Can it be treated?</h2>
<p>Today, <a href="http://www.who.int/mediacentre/factsheets/fs375/en/index.html">around 1.3m</a> people are infected with leishmaniasis every year across the tropics and sub-tropics. Most sufferers have the cutaneous form, as found in Syria, while the visceral form can be fatal. But because it is typically found among the world’s poorest people, it receives little attention in terms of developing new drugs or vaccines and is considered a <a href="https://theconversation.com/is-ebola-diverting-resources-from-other-neglected-diseases-34475">neglected tropical disease</a>.</p>
<p>However, treatments do exist and in a functioning health system drugs can be used to cure the disease. Scientists are still debating the <a href="http://www.cdc.gov/parasites/leishmaniasis/health_professionals/">best treatment</a> for the cutaneous disease but at present we have four different drugs that can be used. The best medicine for visceral leishmaniasis is called <a href="https://www.nlm.nih.gov/medlineplus/druginfo/meds/a682643.html">amphotericin B</a> and when injected it is very efficient at curing the disease. Just a few injections of the drug can be enough to cure the disease, but it does carry the risk of side effects such as fever, headaches and vomiting.</p>
<p>Older drugs have to be given for several weeks to show an effect. For example, when <a href="http://www.dailymail.co.uk/health/article-1191257/Ben-Fogle-I-nearly-lost-half-face-flesh-eating-bug--The-cure-injections-poison.html">TV adventurer Ben Fogle</a> caught the cutaneous disease in Peru a few years ago he was treated with a rather toxic antimony-based drug, which made him feel very ill and lose large amounts of weight but eventually cured him.</p>
<h2>Could it spread more widely?</h2>
<p>In addition to the increasing incidence of the disease in Syria itself, some refugees fleeing the country will carry parasites with them. This could be used by those who oppose taking in refugees by suggesting they will spread disease. But countries receiving refugees need not worry about its introduction.</p>
<p>It is sandflies, not people, that transmit the disease and though they are found throughout the tropics and subtropics, they can’t survive in colder climates. The visceral form of leishmaniasis is already endemic in parts of <a href="http://www.eurosurveillance.org/images/dynamic/es/v18n04/v18n04.pdf">southern Europe</a> including Spain, Italy and the south of France, but the disease tends to only manifest itself in people with weak immune systems such as those infected with HIV. This highlights the fact that people in prosperous regions where nutrition and general health are good are at limited risk.</p>
<p>It is also important to understand that different species of sandfly are responsible for transmission of different <em>Leishmania</em> parasites. Those that transmit the cutaneous disease found in Syria are less common in southern Europe so the chances of increasing transmission of cutaneous leishmaniasis are small. Although Turkey might be at risk of increased incidence of the cutaneous disease due to the flow of refugees from Syria, again it is worth highlighting that people with access to good nutrition and in generally good health are less vulnerable. </p>
<p>Concerns about imported germs, of course, are nothing new. Just last year, European airports were decorated with posters <a href="https://theconversation.com/containing-the-international-spread-of-ebola-30318">warning of Ebola</a>, and those coming from West Africa were subjected to mandatory tests for signs of fever. But we should be careful of warnings of diseases spreading to developed countries, where healthcare systems and levels of public health are much more capable of preventing and treating infectious condition, even in instances where those diseases could spread. Plus the wider availability of treatments in Europe creates an opportunity to provide healthcare to incoming sick refugees.</p>
<p>Given that leishmaniasis cannot be spread to colder countries and is limited by good healthcare, the particular suggestion that it could be carried by refugees holds no force.</p><img src="https://counter.theconversation.com/content/52397/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Barrett receives funding from the Wellcome Trust. He is affiliated with the Wellcome Trust Centre for Molecular Parasitology and the World Health Organisation. </span></em></p>The collapse of Syria’s health system is helping spread leishmaniasis but not in the way some media outlets have reported.Michael Barrett, Professor of Biochemical Parasitology, University of GlasgowLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/486742015-10-07T04:11:42Z2015-10-07T04:11:42ZHow 2015 Nobel Prize drug might rid Africa of ancient scourges<figure><img src="https://images.theconversation.com/files/97488/original/image-20151006-7358-5g1n75.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tanzanian Seif Ramadhan is washed before being treated for elephantiasis. </span> <span class="attribution"><span class="source">Khalfan Said/EPA</span></span></figcaption></figure><p>The <a href="http://www.nobelprize.org/nobel_prizes/medicine/laureates/2015/press.html">announcement</a> that the 2015 Nobel Prize in Physiology or Medicine went to three scientists who developed antiparasitic disease drugs has important implications for sub-Saharan Africa.</p>
<p>Two of the scientists – William C. Campbell and Satoshi Ōmura – shared the prize for the discovery of the drug ivermectin. Ivermectin (trading as mectizan®) is one of the most widely used medicines in Africa. It is used in the mass treatment or prevention of two ancient scourges that have plagued Africa for centuries – <a href="http://www.who.int/mediacentre/factsheets/fs102/en/">elephantiasis</a> and <a href="http://www.who.int/mediacentre/factsheets/fs374/en/">river blindness</a>. </p>
<h2>Understanding the diseases</h2>
<p>Elephantiasis, commonly referred to as LF, is a disease that affects tens of millions of people in Africa, with Nigeria likely having the largest number of cases. It is caused by a parasitic worm, <em>Wuchereria bancrofti</em>, which affects the lymphatics, genitals and breasts. The parasite in turn is transmitted by mosquitoes. </p>
<p>Although not fatal, elephantiasis can severely disfigure its victim, resulting in profound social stigma. By distorting the limbs and other body parts, elephantiasis renders people too sick to work so that elephantiasis hinders economic productivity.</p>
<p>However, there is good news. It was recently estimated that 139 million people in Africa received elephantiasis <a href="http://www.who.int/wer/2015/wer9014/en/">treatments</a> in 2013. This was made possible by the Mectizan Donation Programme along with the World Health Organisation and the Global Programme to Eliminate <a href="http://www.filariasis.org/">Lymphatic Filariasis</a>. </p>
<p>By killing the embryonic microfilaria stages of W. bancrofti, wide-scale delivery and treatment with mectizan can interrupt the transmission of elephantiasis. So far, Togo may be the first African nation to <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0002080">eliminate</a> elephantiasis through this approach. The global goal is to eliminate elephantiasis by <a href="http://www.who.int/neglected_diseases/NTD_RoadMap_2012_Fullversion.pdf">2020</a>. </p>
<p>Similarly, onchocerciasis is also caused by a parasitic worm, <em>Onchocerca volvulus</em>, which is transmitted by black flies that live near fast-flowing streams and rivers. The microfilarial stages of parasitic worm cause disfiguring skin disease, but also invade the cornea to cause blindness. </p>
<p>Between 17 and 30 million people are affected by onchocerciasis in sub-Saharan Africa. Through the <a href="http://www.merck.com/about/featured-stories/mectizan.html">Mectizan Donation Programme</a> and the World Health Organisation’s <a href="http://www.who.int/apoc/en/">African Programme for Onchocerciasis Control</a>, it is estimated that 100 million people were <a href="http://www.who.int/wer/2015/wer9014/en/">treated</a> in 2013.</p>
<p>Because of mass treatment programmes, onchocerciasis has been eliminated in Mali and Senegal. There is optimism that the disease will be eliminated elsewhere.</p>
<h2>A plan to eliminate the diseases</h2>
<p>The discoveries of Campbell and Omura may enable us to eliminate these two diseases some day. But we have a long way to go. For onchocerciasis, there is concern that ivermectin has to be administered for the entire lifespan of the adult parasite, meaning 17 years. This is because ivermectin only targets the microfilarial stages and not the adult worms.</p>
<p>As such, the <a href="http://www.dndi.org/diseases-projects/diseases/helminth-infections/dndi-strategy.html">Drugs for Neglected Tropical Diseases Initiative</a> is working to develop new medicines targeting adult worms. This is in addition to efforts by the <a href="http://www.lstmed.ac.uk/about/people/professor-mark-taylor">Liverpool School of Tropical Medicine</a>. In parallel, the <a href="http://www.sabin.org/">Sabin Vaccine Institute</a> is working with a consortium of partners in the <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0003422">Onchocerciasis Vaccine for Africa Initiative</a> to develop preventative vaccines.</p>
<p>In the meantime, the use of ivermectin in Africa is being expanded by using this medicine as part of a <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0020336">package</a> of “rapid impact” medicines. This includes three other medicines for intestinal worms, schistosomiasis, and trachoma. All the medicines are donated by major pharmaceutical companies.</p>
<p>With these generous contributions and support from bilateral agencies such as the <a href="http://www.neglecteddiseases.gov/index.html">US Agency for International Development</a> and the <a href="https://www.gov.uk/government/organisations/department-for-international-development">UK Department for International Development</a>, more than 450 million people have been treated for neglected tropical diseases worldwide.</p>
<p>These and other partners, including the <a href="http://www.globalnetwork.org/">Global Network for Neglected Tropical Diseases</a> and the END Fund, are now working with the G7 countries to support mass treatment for these diseases of poverty. At the same time, we are developing new <a href="http://www.sabin.org/programs/vaccine-development">vaccines</a> for diseases such as hookworm and schistosomiasis. These activities will occur through the sustainable development <a href="https://sustainabledevelopment.un.org/post2015/summit">goals</a> recently adopted at the UN General Assembly.</p>
<p>We can control and eliminate neglected tropical diseases within a decade. However, it will require continued advocacy, expanded treatment programs and scientific innovations.</p><img src="https://counter.theconversation.com/content/48674/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Hotez, MD, PhD, is president of the Sabin Vaccine Institute (Sabin), Texas Children’s Hospital Endowed Chair for Tropical Pediatrics and dean of the National School of Tropical Medicine at Baylor College of Medicine. He also serves as U.S. Science Envoy for the White House and State Department.</span></em></p>The drug that led to two scientists wining the Nobel Prize for Physiology or medicine has made a significant difference for those suffering from elephantiasis and river blindness.Peter J Hotez, Dean of the National School of Tropical Medicine and Professor of Pediatrics and Molecular Virology & Microbiology, Baylor College of Medicine Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/476272015-09-22T22:46:31Z2015-09-22T22:46:31ZMore is less? Health in the Sustainable Development Goals<figure><img src="https://images.theconversation.com/files/95661/original/image-20150922-31492-1yyvl8i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Improving maternal mortality and ending preventable deaths in children are some of the health targets in the Sustainable Development Goals.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/dfataustralianaid/10656362374/">Department of Foreign Affairs and Trade/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p><em>On September 25, world leaders will meet in New York to formalise the new Sustainable Development Goals. These 17 goals will guide efforts to reduce poverty and increase well-being, without destroying the Earth. The Conversation is looking at <a href="https://theconversation.com/au/topics/un-sustainable-development-goals">how we got here, and how far we have to go</a>.</em></p>
<p>Health has secured its place as one of the 17 Sustainable Development Goals, expanding its scope from the Millennium Development Goals. But without clear mechanisms to report, finance or engage other sectors, could more end up as less?</p>
<p>Most of the people I know who work in global health were not confident that health would do well out of the <a href="https://sustainabledevelopment.un.org/">Sustainable Development Goals (SDG)</a>. My colleagues in the <a href="http://www.scielosp.org/pdf/bwho/v91n1/a02v91n1.pdf">Go4Health research project</a>, an international consortium of researchers advising the European Union on the development of the post-2015 development agenda, were cautious about what to expect. As were many of the senior technocrats in the United Nations agencies, development banks and related organisations whom we interviewed. </p>
<p>The call for the Sustainable Development Goals put to the <a href="http://www.uncsd2012.org/">Rio 20+ Conference on Sustainable Development</a> hadn’t, after all, mentioned health. And in early proposals by advocates such as <a href="http://www.sciencedirect.com/science/article/pii/S0140673612606850">Jeffrey Sachs</a>, it seemed marginal, just one aspect of sustainable social development. </p>
<p>But in its precursor, the <a href="http://www.un.org/millenniumgoals/">Millennium Development Goals (MDG)</a>, health had dominated the eight goals. Three were directly focused on reducing child mortality, maternal mortality and deaths from AIDS, tuberculosis and malaria. And health was also integral to other goals addressing poverty, water and sanitation, and gender. </p>
<h2>Securing a place for health</h2>
<p>In 2013, we were being warned that “health has had its turn”. The focus was most likely to shift to climate change and a sustainable environment, with sustainable economic development the key to global change.</p>
<p>But three factors got health over the line in the final formatting of the SDG. First, the qualified success of the MDG; there was enough progress to argue the goals had mobilised global solidarity, but with substantial shortfall in most health targets. Sub-Saharan Africa, in particular, had not achieved most of its goals. </p>
<p>The second factor was the substantial growth in development assistance that specifically targeted health. Three sources dominated: the United States and United Kingdom governments and the <a href="http://www.gatesfoundation.org/">Bill & Melinda Gates Foundation</a>. Their priority in development assistance was health, and together they dominated international aid financing for development.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/95662/original/image-20150922-16668-1ew6e78.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/95662/original/image-20150922-16668-1ew6e78.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/95662/original/image-20150922-16668-1ew6e78.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/95662/original/image-20150922-16668-1ew6e78.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/95662/original/image-20150922-16668-1ew6e78.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/95662/original/image-20150922-16668-1ew6e78.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/95662/original/image-20150922-16668-1ew6e78.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Health has dominated international aid financing for development from major donors such as the Bill & Melinda Gates Foundation.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/stevendepolo/5437288053/in/photolist-9htwiK-arXw9-9sk6t4-dNQu1v-67rRe3-e2B8AQ-5mVd3r-bmm6e6-asMv8U-72b66a-5u4pbp-5Rhnwj-9NfxsR-66Y4nX-982yDF-tvqZg-7fNUg1-eyPuti-7jQvaV-anfueY-goATh5-8Be3oY-goBwAa-e3eTe8-9vnwcd-iYAtXY-beXpRF-amEmN7-a4UFDb-gp4Lad-8ZYoqm-5oBugB-a2XMH6-7ei7LP-gp5j2D-3muC1c-jELXgq-J36EE-a4UQ9h-6B4Cz5-dSk2s-7wxf2R-8qR7AE-7wBdLU-a4RWRZ-2yPXDW-6evSiG-6haSGo-7wBdJN-8GEaRN">Steven Depolo/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>The third factor was the World Health Organisation’s (<a href="http://www.who.int/en/">WHO</a>) persistent advocacy for <a href="http://www.who.int/universal_health_coverage/en/">universal health coverage</a>. They saw this as the health goal that could extend health service coverage to the whole population, ensure the quality and scope of those services, and protect those seeking health care from significant financial risk. </p>
<p>In protracted SDG negotiations, universal health coverage acted as a proxy for health systems more broadly. Having it as a preferred goal focused the energies of WHO and its allies, and threats to the idea of universal health coverage mobilised health systems advocacy from UN member states, as well as key donors and civil society.</p>
<h2>The world we want</h2>
<p>The major criticism the MDG faced was that they weren’t consultative. They were a technical exercise, put together by a room full of UN bureaucrats and included in Kofi Annan’s 2001 report following the <a href="http://www.un.org/en/events/pastevents/we_the_peoples.shtml">Millennium Summit</a>, without clear member state endorsement. </p>
<p>The SDG process would not be the same. In all, 12 months of UN-driven talks from 2012 to mid-2013 saw 11 thematic consultations (including one on health), close to a hundred country consultations, and a “<a href="http://www.beyond2015.org/world-we-want-2015-web-platform">world we want</a>” website that allowed hundreds of thousands to express their opinions.</p>
<p>Despite this extensive consultation, the politics of the SDG have been unpredictable. Universal health coverage, for instance, didn’t make it as the SDG health goal. But with the process shifting to the member states’ open working group in 2013, advocacy for health was championed by states who valued its transformative potential. And they have been successful in securing its place in the final draft of the SDG. </p>
<p><a href="https://sustainabledevelopment.un.org/topics">Goal 3</a> (Ensure healthy lives and promote well-being for all at all ages) includes nine targets and four “means of implementation”. It may be only one goal, but it covers territory that’s much more expansive than the three health-specific MDG.</p>
<h2>One goal, but more health targets</h2>
<p>In the <a href="https://sustainabledevelopment.un.org/topics">SDG</a>, the continuing agenda of the MDG has been ramped up several notches: reducing the global maternal mortality ratio to less than 70 per 100,000 live births; ending preventable deaths in newborns and under-fives; and ending the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases. </p>
<p>Ambitious indeed, but at least it’s territory we’re familiar with.</p>
<p>But beyond these, new targets seek to reduce the premature death from non-communicable or lifestyle diseases that dominate the global burden of disease in both developed and developing countries: heart disease, stroke and diabetes. And promote mental health and well-being, however that might be defined. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/95656/original/image-20150922-31528-vkwblv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/95656/original/image-20150922-31528-vkwblv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=459&fit=crop&dpr=1 600w, https://images.theconversation.com/files/95656/original/image-20150922-31528-vkwblv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=459&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/95656/original/image-20150922-31528-vkwblv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=459&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/95656/original/image-20150922-31528-vkwblv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=577&fit=crop&dpr=1 754w, https://images.theconversation.com/files/95656/original/image-20150922-31528-vkwblv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=577&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/95656/original/image-20150922-31528-vkwblv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=577&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Among the SDG health targets is the aim to strengthen prevention and treatment of substance abuse — including alcohol — and the effects of hazardous chemicals and pollution.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/neilspicys/2930429035/">NeilsPhotography/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Further targets strengthen prevention and treatment of substance abuse — including alcohol — and the effects of hazardous chemicals and pollution. And aim to halve deaths and disability from road traffic accidents.</p>
<p>Over the past 15 years, we’ve set up reporting mechanisms that allow us to track progress on the MDG. For this additional raft of targets, reporting mechanisms don’t yet exist in many countries. Many of the targets don’t yet have clear indicators or baseline data and, for several of them, there’s limited evidence on how to address this expanded agenda globally. </p>
<p>In many ways, these first seven targets follow the MDG model, focused on single disease entities. For many of these targets, however, we’ve embraced issues that are <a href="http://www.biomedcentral.com/content/pdf/1744-8603-10-18.pdf">well beyond the scope of the health sector</a> to manage alone. But the SDG document doesn’t offer any proposal for the multi-sectoral mechanisms that will be needed to address well-being, dietary and lifestyle change, environmental health and trauma from road accidents. </p>
<h2>But is more less?</h2>
<p>There are two health service targets — universal health coverage and access to sexual and reproductive health services — but there’s no structural connection that links them to the seven disease targets. This failure to integrate bodes poorly for imagining health into what is a very complex, inter-related development agenda.</p>
<p>The four “means of implementation” targets reflect the need to enshrine hard-won global political concessions for health. They include strengthening the <a href="http://www.who.int/fctc/en/">Framework Convention on Tobacco Control</a>, which is crucial to reducing the burden of non-communicable disease; supporting development of vaccines and medicines while preserving the protections negotiated through the World Trade Organisation; financing, resourcing and retaining the health workforce needed for developing country health systems; and extending risk surveillance and response capacity to all nations.</p>
<p>Health has secured its place in the SDG, but my anxiety remains. <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001487">I have argued</a> that one of the disadvantages of the MDG was the way they targeted specific issues. By achieving progress for those issues, they narrowed aid priorities and distorted health systems development. But now I’m faced with a massively expanded — but still not exhaustive — set of targets in health, with no comprehensive strategy for addressing them. </p>
<p>The overall sustainable development agenda of 17 goals and 269 targets is <a href="https://www.mja.com.au/journal/2015/202/6/countdown-health-post-2015-un-sustainable-development-goals">extremely unwieldy</a>. And the financial climate for development is less optimistic than it was in 2000. The funding estimates for achieving them fall well short of the currently available resource envelope. </p>
<p>Sustainable development depends on social, environmental and economic transformation. But in terms of meeting this challenge for health by 2030, I can’t help wondering if more isn’t less.</p><img src="https://counter.theconversation.com/content/47627/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Hill receives funding from the European Union’s Seventh Programme for research, technological development and demonstration (grant ref: HEALTH-F1-2012-305240) and the Australian Government’s National Health and Medical Research Council–European Union Collaborative Research Grants (grant ref: 1055138).</span></em></p>Health has secured its place as one of the 17 Sustainable Development Goals. But without clear mechanisms to report, finance or engage other sectors, could more end up as less?Peter Hill, Associate Professor of Global Health Systems, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/400472015-05-22T10:18:14Z2015-05-22T10:18:14ZExplainer: what is Chagas disease?<p>According to an article in the Journal of the American Medical Association (JAMA), in a Los Angeles clinic treating patients with heart failure, about <a href="http://dx.doi.org/10.1001/jama.2015.1867">20% of Latin American patients</a> have Chagas disease. What is that?, you might wonder.</p>
<p>Chagas is a parasitic infection that is endemic in <a href="http://www.who.int/mediacentre/factsheets/fs340/en/">21 countries</a> in Central and South America and affects an estimated 6-7 million people worldwide. This disease is one of several so-called neglected tropical infectious diseases that have significant worldwide morbidity (the incidence of a disease) and mortality. It can, as the JAMA article suggests, lead to severe health complications. But in the US, the disease is relatively rare, though incidence is starting to increase. </p>
<p>This increase represents an opportunity for the medical community to learn about this disease and find ways to help patients who are infected and to thwart the risks of potential infection of others. </p>
<h2>So what exactly is Chagas disease?</h2>
<p>Sometimes called American, or South American, trypanosomiasis, Chagas is an infection with the protozoan parasite <em>Trypanosoma cruzi</em>. People can become infected by the blood-feeding triatomine bug, the feces of which contains parasites that contaminate the bite wound or mucous membranes which leads to infection.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/82465/original/image-20150520-11440-rfgowl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/82465/original/image-20150520-11440-rfgowl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/82465/original/image-20150520-11440-rfgowl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=511&fit=crop&dpr=1 600w, https://images.theconversation.com/files/82465/original/image-20150520-11440-rfgowl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=511&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/82465/original/image-20150520-11440-rfgowl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=511&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/82465/original/image-20150520-11440-rfgowl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=643&fit=crop&dpr=1 754w, https://images.theconversation.com/files/82465/original/image-20150520-11440-rfgowl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=643&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/82465/original/image-20150520-11440-rfgowl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=643&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Panstrongylus chinai, one of several different types of triatomine insects that are vectors for <em>T. cruzi</em>.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>This isn’t the only mode of infection. An infected mother can pass the infection to her developing fetus. The parasite can also be ingested, either by consuming infected animals or drinking fluid contaminated with parasites. There have been reports of infection from <a href="http://jid.oxfordjournals.org/content/201/9/1308">consumption of juice</a>, prepared from acai berries or other fruits or imported sugar cane, which is contaminated during processing by immature triatomine bugs carrying the parasite. The parasite can also be acquired from infected human blood products and tissue through blood transfusion or organ transplantation. </p>
<p>Once inside a human, parasites enter the bloodstream or the lymphatic system (composed of lymph nodes and vessels that contain a large bulk of immune cells), from which they are distributed throughout the body. </p>
<p>While these parasites infect many different kinds of humans cells, they preferentially infect muscle cells in the heart and those lining the gastrointestinal tract. This leads to the destruction of host tissue, resulting in chronic inflammation and scarring of the heart and gastrointestinal tract that gives rise to the heart disease or gastrointestinal problems that occur in about <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4015570/">20%-30%</a> of those infected. The factors which make some people develop long-term symptoms while others do not are not well understood. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/79035/original/image-20150423-3136-1i2clby.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/79035/original/image-20150423-3136-1i2clby.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/79035/original/image-20150423-3136-1i2clby.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=457&fit=crop&dpr=1 600w, https://images.theconversation.com/files/79035/original/image-20150423-3136-1i2clby.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=457&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/79035/original/image-20150423-3136-1i2clby.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=457&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/79035/original/image-20150423-3136-1i2clby.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=574&fit=crop&dpr=1 754w, https://images.theconversation.com/files/79035/original/image-20150423-3136-1i2clby.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=574&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/79035/original/image-20150423-3136-1i2clby.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=574&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The life cycle of <em>Trypanosoma cruzi</em>, the causal agent of American Trypanosomiasis. The life cycle is complex, involving parasite development in both insect and mammalian hosts.</span>
<span class="attribution"><span class="source">CDC/Alexander J da Silva, PhD, Melanie Moser.</span></span>
</figcaption>
</figure>
<h2>Chagas in the US</h2>
<p>People in poor rural regions in Central and South America are particularly at risk for acquiring Chagas disease, especially if they live in substandard housing which allows entrance of the insects that carry <em>T. cruzi</em>. In heavily infested dwellings, adult insects can breed, giving rise to immature insects that become infected with the parasite. Another risk factor is how close homes are to a reservoir of infected animals.</p>
<p>The risk is lower in the US. In the last 60 years, fewer than 30 people have been reported to have caught Chagas disease in the US. The overall number of people with Chagas in the US is estimated at approximately 300,000, most of whom acquired it <a href="http://www.ncbi.nlm.nih.gov/pubmed/21976603">outside the US</a> in countries where Chagas is endemic. These patients were likely infected many decades before cardiac or gastrointestinal symptoms arise. It is estimated that the health-care associated costs in the US and Canada related to Chagas disease is nearly <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3763184/">US$119 million annually</a>. </p>
<p>In the US, there are many animal reservoirs that can carry <em>T. cruzi</em>, such as raccoons, opossums, ringtails, skunks, armadillos, coyotes, bobcats, badgers, foxes and rodents such as woodrats, squirrels, rats and mice. However, domesticated animals such as cats and dogs can also <a href="http://dx.doi.org/10.1128/CMR.00005-11">harbor the parasite</a>. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/80135/original/image-20150501-23856-s0bdbl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/80135/original/image-20150501-23856-s0bdbl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=493&fit=crop&dpr=1 600w, https://images.theconversation.com/files/80135/original/image-20150501-23856-s0bdbl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=493&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/80135/original/image-20150501-23856-s0bdbl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=493&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/80135/original/image-20150501-23856-s0bdbl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=619&fit=crop&dpr=1 754w, https://images.theconversation.com/files/80135/original/image-20150501-23856-s0bdbl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=619&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/80135/original/image-20150501-23856-s0bdbl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=619&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Opossums are one of many animal reservoirs for <em>T. cruzi</em> in the US.</span>
<span class="attribution"><a class="source" href="http://commons.wikimedia.org/wiki/File%3AOpossum_2.jpg">Cody Pope, via Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Triatomine insects are found in at least 28 states in the US, mainly in the southern regions. Recent cases reported in the US have been linked to <a href="http://dx.doi.org/10.4269/ajtmh.14-0238">outdoor activities</a> such as camping, hunting and gardening, leading to insect exposure, rather than the more traditional risk factors usually associated with insect exposure in endemic countries.</p>
<p>Since the disease can be transmitted through the transfer of infected blood and tissue, these must be screened for the presence of the parasite. Increasingly, Chagas is detected through these screening procedures, which is a challenge for the medical community because Chagas is a relatively rare disease in the US and many healthcare providers do not have experience with the management of this problem. </p>
<h2>What happens if you get Chagas?</h2>
<p>People with Chagas can remain asymptomatic for long periods, which means they can unknowingly bring the disease into other regions of the world. Increased international travel is the main reason that there are more cases of Chagas appearing outside of regions where it is endemic.</p>
<p>Those at the early phase of infection with <em>T. cruzi</em> can be completely asymptomatic or have nonspecific flu-like symptoms such as fever, chills or body aches which are temporary. Some infected people may develop localized swelling at or near the site of the insect bite that contains parasites and causes a local inflammatory reaction.</p>
<p>After the acute phase passes, infected people usually remain asymptomatic and only develop the chronic symptoms decades later. </p>
<p>Regarding treatment, there are two anti-parasitic medications (called benznidazole and nifurtimox) that can be used for both those who test positive and are asymptomatic and those who have symptoms of chronic disease. The drugs can have significant side effects, and patients on these medications need close follow-up with their physicians. These drugs are not routinely available in the US and must be obtained by physicians through the Centers for Disease Control and Prevention (CDC). </p>
<p>Although there are research labs working in the development of newer and safer anti-parasitic agents, there is little in the way of large-scale investment in anti-parasitic drug development by the pharmaceutical industry. There are currently no vaccines available for the prevention of Chagas disease.</p>
<p>The way to prevent Chagas disease is to avoid contact with triatomine bugs. Spraying programs for insect control are also important, as is avoiding the close proximity of animal dwellings to houses or the cohabitation of humans with potentially infected animals. Detection and control of animal reservoirs and screening of people living in geographical areas at risk for Chagas are also important.</p><img src="https://counter.theconversation.com/content/40047/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bradford McGwire receives funding from The American Heart Association, Fulbright Commission and The Ohio State University.</span></em></p>This parasitic infection is endemic in Central and South America, and can lead to serious health complications. Though rare in the US, incidence is starting to increase.Bradford S McGwire, Assistant Professor-Division of Infectious Diseases, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/344752014-12-08T10:59:28Z2014-12-08T10:59:28ZIs Ebola diverting resources from other neglected diseases?<p>Thanks in part to the Ebola crisis, neglected diseases have grabbed the world’s attention. These diseases predominantly affect developing nations with limited resources to fund research, pay for treatments, and support public health infrastructure. The commercial prospects for drugs and treatments targeting neglected diseases are also limited, which in turn means that there is little research and development. </p>
<p>But now some scientists worry that increased funding for Ebola will draw funds away from other research programs <a href="http://www.the-scientist.com/?articles.view/articleNo/41427/title/Funding-Research-in-Africa/">targeting diseases</a> such as malaria.</p>
<p>As the outbreak continues, more resources are being poured into Ebola drug and vaccine development. A number of public and private sector stakeholders are now heavily involved in development and clinical trials. But companies like Tekmira and Mapp Biopharmaceutical, the producer of the Ebola treatment ZMapp, need larger partners to move investigational drugs past the early stages of clinical development, and to ramp up production once the Food and Drug Administration (FDA) approves a drug or vaccine for marketing.</p>
<p>With funding for most neglected diseases stagnating instead of growing, the Ebola crisis may, however, be diverting attention away from the resources required to continue to combat diseases with a substantially larger disease incidence. </p>
<p>Moreover, experts say that the Ebola outbreak has produced a “silent killer.” Thousands of hidden cases of malaria, tuberculosis, pneumonia, and typhoid are going untreated. Thomas Teuscher of <a href="http://www.rollbackmalaria.org/">Roll Back Malaria</a> says under-treatment of malaria has been <a href="http://www.bigstory.ap.org/article/934668a58648419c9f99e6a315de23d1/ebola-hits-health-care-access-other-diseases">particularly conspicuous</a> amid the Ebola epidemic. </p>
<h2>Investing in neglected diseases</h2>
<p>Funding increases targeting malaria, HIV/AIDs and tuberculosis have cut infection rates and boosted survival.</p>
<p>In 1999, the global investment in neglected disease drug development was less than US$100 million. Around 2000, funding began to increase significantly, due to an influx of resources from governments, philanthropies, product development partnerships (PDPs) between public and private sector, and <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000030">private industry</a>. By 2008, investment in neglected disease drug development rose to nearly <a href="http://www.ncbi.nlm.nih.gov/books/NBK62528/">US$3 billion</a>. Since then, however, funding has plateaued. </p>
<p>Most of this funding has been directed at just three diseases: HIV/AIDS, malaria and tuberculosis. These three diseases are called the “Big Three” as they take up two-thirds of the total number of dollars invested in neglected diseases research. Spending on research for pediatric treatments for HIV/AIDS accounts for about one-third of neglected disease funding. Malaria and tuberculosis account for <a href="http://www.policycures.org/downloads/GF_report13_all_web.pdf">17% and 16%</a>, respectively. It’s worth noting that resources targeting Ebola drug and vaccine development were negligible through 2012.</p>
<p>This funding increase appears to have produced results. Since 2000, 46 new drugs have been approved, treating a multitude of diseases, including HIV/AIDS, malaria, leishmaniasis, and typhoid. And from 2009 through 2013, regulatory agencies approved <a href="http://www.ncbi.nlm.nih.gov/pubmed/24906971">20 new products</a>, ranging from vaccines to tests and treatments for tuberculosis, Chagas disease, and cholera. </p>
<p>Because of these new products and better access to existing drugs, the number of new HIV infections among children worldwide has decreased by <a href="http://apps.who.int/iris/bitstream/10665/82058/1/WHO_HIS_HSI_13.1_eng.pdf?ua=1&ua=1">over 50% since 2001</a>. The death rate from tuberculosis has decreased by 45% since the World Health Organization declared it a global public health emergency in 1993. Malaria mortality rates have fallen by <a href="http://www.who.int/features/factfiles/malaria/en/">42% worldwide</a> since 2000.</p>
<p>But, the inclusion of newly approved products on the World Health Organization’s Essential Drug List has been slow and limited, with <a href="http://www.ncbi.nlm.nih.gov/pubmed/24906971">only 44%</a> of products approved after 2000 added. This list contains drugs that meet the health care needs of the majority of the population, and therefore should be available at all times in adequate amounts and in appropriate dosage forms. Drug developers could do more to facilitate access, in particular, by working closely with the World Health Organization to expedite assessment of the clinical- and cost-effectiveness of new approvals.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/66288/original/image-20141204-7277-6tjs0k.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/66288/original/image-20141204-7277-6tjs0k.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/66288/original/image-20141204-7277-6tjs0k.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=474&fit=crop&dpr=1 600w, https://images.theconversation.com/files/66288/original/image-20141204-7277-6tjs0k.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=474&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/66288/original/image-20141204-7277-6tjs0k.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=474&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/66288/original/image-20141204-7277-6tjs0k.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=596&fit=crop&dpr=1 754w, https://images.theconversation.com/files/66288/original/image-20141204-7277-6tjs0k.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=596&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/66288/original/image-20141204-7277-6tjs0k.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=596&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption"></span>
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<p>Annually the “Big Three” still cause over 3.5 million deaths across the globe. Other diseases, such as leishmaniasis and Dengue fever, contribute to over 20,000 deaths each.</p>
<p>Malaria and HIV/AIDS appear to have benefited most from increased funding, while there has been much less success in other diseases, such as trachoma, river blindness, Buruli ulcer and Dengue fever. This uneven progress indicates funding could be better targeted. </p>
<p>Moving forward, efforts by product development partnerships, the pharmaceutical industry and governments worldwide to address neglected diseases must expand. Additionally, funding of neglected disease drug development should be a function of both the disease burden (morbidity and mortality) suffered and the lack of treatment alternatives.</p><img src="https://counter.theconversation.com/content/34475/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joshua Cohen does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Some experts worry that the Ebola crisis is diverting attention and resources away from neglected diseases with a substantially larger disease incidence.Joshua Cohen, Research Associate Professor, Tufts Center for the Study of Drug Development, Tufts UniversityLicensed as Creative Commons – attribution, no derivatives.