By Pranay Lal & Rajeev Sadanandan
Neglected tropical diseases (NTDs) include a range of infectious diseases that cause substantial illness. They are mainly prevalent in tropical areas, where they affect impoverished, underserved communities. NTDs cause devastating health, social and economic consequences. WHO estimates that more than 1.7 billion people require treatment for at least one NTD every year. There are 20 officially recognised NTDs by the WHO. WHO in 2021 reported that 16 countries accounted for 80% of the global NTD burden.
Twelve years ago, a group of donors like the World Bank, the Bill & Melinda Gates Foundation, WHO, and representatives of pharmaceutical companies and governments gathered at London’s Royal College of Physicians. They pledged their commitment to putting an end NTDs. This became the London Declaration, the first to acknowledge the global burden of NTDs. It is commemorated as ‘day’ only since 2021, after the UAE proposed it, at the 74th World Health Assembly (2021). So much for delay and neglect of tropical diseases of the poor. On 31 May 2021, the Seventy-fourth World Health Assembly recognized 30 January as World Neglected Tropical Diseases Day through the unanimous approval of decision WHA74(18) by WHO Member States. This Day is now one of the 11 Global Health Days and 2 Global Health Weeks recognized by WHO.
The challenge is also of how many NTDs exist. It is not the disease or the pathogen that causes it that is neglected. It is the people that are left out of the purview of health systems, or for whom medicines, treatment, and health services do not exist. Several marginalised communities spread across countries suffer from diseases that are not yet common knowledge. It took Africa’s health advocates over a decade to get WHO to recognise a painful face-distorting infectious disease in October 2023.
Called Noma, this disease is a social marker of extreme poverty and malnutrition. It starts by the most vulnerable among the vulnerable. Malnourished children between the ages of two and six years with little access to clean water and food develop a severe gangrenous mixed bacterial infection that starts as an inflammation of the gums. If not treated early, it spreads quickly to destroy facial tissues and bones, leading to disfigurement and even death. That’s where the disease gets its name – from Latin, meaning to feed and spread sores. There are no real numbers of victims of Noma. It occurs widely across sub-Saharan Africa, with a handful of cases being reported from Americas and Asia. The infection spreads rapidly across children, across households and communities, leading to a life of stigma and castigation. If it is to illustrate how the status of the sufferers lead to neglect of diseases, it is a powerful example. A disease of this nature ought to have attracted public health and research interest sooner. The reason it did not is that it occurred in Africa, affected the extreme poor and did not have the potential to be transmitted to the better-off; a characteristic that defines NTDs as a group.
Last year saw tremendous progress across the world to inch towards addressing the problems of NTDs. Seven NTDs were eliminated as a public health problem in six different countries and the transmission of one NTD was interrupted. Post-COVID-19 pandemic, there is fresh energy to fight NTDs. In 2023, several disease control organisations came together to generate political will and create an enabling environment for countries to achieve the WHO NTD roadmap targets and deliver the SDG NTD goal to end NTDs by 2030. More investments are coming from new coffers. The year 2023 saw around $1.5 billion mobilised, 21 billion worth of donated treatments were committed by pharma companies. Despite this, elimination looks like a distant dream. Some NTDs with proven vaccines and effective treatments could have been limited or even eradicated, but have not been. Trachoma, a chronic infection of the conjunctiva, as a case in point. The WHO adopted the Global Elimination of Trachoma by 2020 in 1993, but it has yet to achieve significant progress. Better sanitation, fly control, and topical antibiotic eyedrops can halt this infection. Migration and civil war also remain an important driver of the disease. Yet, big successes from small nations continue to stream in, raising hope. Despite post-COVID challenges, Benin and Mali eliminated trachoma in May 2023. Cape Verde achieved a historic milestone on 12 January, becoming the third African country to eliminate malaria (after Mauritius in 1973, and Algeria in 2019).
In May 2023, the WHO announced that Bangladesh (and later, Lao PDR in October) had eliminated the mosquito-transmitted worm infestation called filariasis. In October, the WHO declared Bangladesh as the first country to have eliminated visceral leishmaniasis (or kala-azar). Another neighbouring country, Sri Lanka eliminated malaria and filariasis much earlier.
India has had significant successes in bringing down the burden of NTDs. Sustained efforts have made kala-azar more manageable (from averaging ten thousand in mid-2010s to 520 in 2023). India’s Yaws Eradication Programme was launched in 1996 and has had no case since 2003. India was declared guineaworm-free in 2000 (the deadline was set to 1991, but was subsequently postponed to 2009, 2015, 2020 and is now at 2030.). Elimination of lymphatic filariasis by 2027 remains India’s priority for the Government of India. It is prevalent in 256 districts but concentrated in four states (UP, Odisha, Telangana, and Bihar) which have 65% of the cases. Although India has achieved the elimination of leprosy as per WHO criteria, there were still 75,394 cases reported in 2021-22. The endgame for leprosy needs greater political commitment and agency.
NTD initiatives received a $777 million boost during the COP28 climate summit. Some advocates see that donor commitment will fall short. They cite the World Bank’s 2017 report, which just preventive chemotherapy for five NTDs could cost as little as US$750 million annually during 2015–20. It would have reduced to US$300 million annually in 2020–30. Importantly, these costs were deemed feasible for the majority of endemic countries, representing less than 0.1 percent of their domestic health expenditure. In other words, the report emphasizes the need to frontload funding gradually taper it as control and elimination goals get realised. Despite the positive infusion of investments, concerns linger, especially with the surge of climate-driven diseases like malaria, dengue, Japanese encephalitis, and chikungunya. The World Malaria Report from December 2023 outlines challenges in malaria prevention, with global cases reaching an alarming 249 million in 2022, 16 million more than the pre-pandemic level. The report underscores the critical need for sustained funding and enhanced efforts to combat spread of malaria amid escalating numbers.
Tragically, some donors continue to play truant to past commitments. At COP28, the UK government announced that it had increased its contribution to climate and health by another £100mn, and another £80mn for health systems. What it had done was to cut funding NTDs and assign these into new buckets. Thankfully, attentive public health advocates and a few British MPs were able to call this out.
The donor community must restore its credibility by scaling up its contribution to NTD control. Equally national governments must increase the salience of NTDs in public health discourse and make health systems deliver on containing and eliminating them. The scope of human suffering on a global scale renders any indifference inexcusable. The prospect of eradicating malaria and neglected tropical diseases is not a distant mirage; rather, it stands as a tangible stride towards a more equitable world. The elimination of malaria and NTDs is possible, and it will be a small step to a more equal world when it is achieved. One step towards this is to improve global governance of infectious disease control, which addresses regionally and locally-prevalent diseases (or NTDs).
(Pranay Lal is a Senior Adviser to the Health Systems Transformation Platform (HSTP), New Delhi. Rajeev Sadanandan is the CEO of HSTP and a former Health Secretary of Kerala. Views expressed are personal and do not reflect the official position or policy of the FinancialExpress.com.)
