Brother, Can You Spare a Dime (or Five)?

Neglected Tropical Disease (NTD) is a catchall phrase attached to a group of parasitic and bacterial infections that plague many parts of the world but can and have been treated successfully by a combination of public health control measures and inexpensive drugs.  The NTDs, typically listed as the helminth infections (ascariasis, hookworm infection, and trichuriasis), lymphatic filariasis, onchocerciasis, dracunculiasis, schistosomiasis, Chagas disease, human African trypanosomiasis, leishmaniasis, Buruli ulcer, leprosy, and trachoma, afflict many people (1.6 billion infected, 2 billion at risk) and have low mortality, but, worse, confer high morbidity with long periods of suffering and often a lifetime of disablement (blindness, total incapacity, or partial disability), and hence have a devastating effect on societies in the endemic areas (Kaiser Fnd Fact Sheet).  The treatment of NTDs is widely acknowledged as one of the most cost-effective in global health, and their elimination has been the object of concerted international effort of multiple groups for the past 10 years, e.g., the USAID’s Neglected Tropical Diseases Initiative, a 5-year, $350 million initiative to provide treatment to more than 300 million people in Africa, Asia, and Latin America, started in 2008 (USAID NTDI).  But, according to a recent commentary by a NTD researcher and advocate (Molyneux 2010), the effort has been under-funded (only 0.6% of all development assistance is aimed at NTD) and many challenges remain, the primary being delivery of the treatments.

A leading NTD advocacy group is the Sabin Vaccine Institute (Sabin Institute) through its subsidiary programs, the Global Network for Neglected Tropical Diseases (NTDGN) and the End the Neglect 2020 campaign (ETN 2020).  The latter is funded by a 2009 $34 million grant from the Gates Foundation (ETN press release), some of which the Sabin put into a marketing effort that includes all the requisites for modern global health advocacy fund-raising:  videos, pictures of smiling kids, fund-raising “challenges” with prizes, a deadline for the “cure,” merchandise, and a sound bite, “Just 50 Cents” (Just 50 Cents).  Because I am interested in solving the delivery problem in global health there were two aspects of the campaign that caught my attention.  The first is the Just 50 Cents statement which means “A donation of just 50 cents can provide treatment for the seven most common neglected tropical diseases (NTDs) to an individual for an entire year.”  I would like to know how the Sabin is delivering or plans to deliver interventions at this price point.  The second is the “investment book” created by the campaign, according to the press release, “describing specific NTD investments that individuals or institutions can make, with concrete pay-offs demonstrated in terms of improved health.”

My quick search of the Sabin and NTDGN sites turned up no specifics and no download for the investment book, but a posted transcript suggested that the books were only available at the campaign’s launch (Davos Transcript 2009).  As for the 50 cent solution, it’s likely originator is Peter Hotez, president of the Sabin, who cites it as the price for a “rapid impact package” of drugs and their delivery to treat seven of the NTDs (Hotez briefing at CHP Fnd).  According to the Global Network, this package is being used by Network members (NTDGN Benefits), although, according to a recent interview with Hotez, data on how many and where is not available (TropIKA.net 2010) and the recent WHO report on NTD control does not mention their use but their need (WHO NTD Report 2010).  So it’s not clear if this price is based on experience or extrapolated from research.  I looked for citations of research on costs for NTD treatment using this the package and did not find any; however, my guess is that it is an estimated number based on data collected for successful campaigns against specific NTDs, e.g. against worms in Laos ($0.13 per child per year), against lymphatic filariasis in seven countries ($0.07 to $2.27 per person per year), and against onchocerciasis in Africa ($0.58 per treatment) as cited by Conteh et al. (Conteh et al. 2010).

Conteh et al. is a substantial summary of the research to date on the socio-economic impact of NTDs and the costs and cost-effectiveness of treatments and their possible financing strategies.  In contrast, last fall’s WHO report, “Working to overcome the global impact of neglected tropical diseases” (WHO NTD Report 2010), has many general statements and tepid recommendations, apparently seeing its role to “foster” technical expertise (page 22) rather than lead the effort (c.f., TropIKA.net article).  Contech et al. point out the importance of continued involvement of the pharmaceutical companies which have donated billions of does of drugs and are committed to future donations, that the cost of past programs have been shared about 50/50 between the governments of the countries involved and donors, and that cost per DALY (disability-adjusted life year) averted of NTD treatments have been less than those for HIV/AIDS and about the same for TB.  Finally, they find that integration of efforts and increased scale (up to a point) yield real benefit.  Whither the NTD fight?  To quote Molyneux (Molyneux 2010):  “If the global health community, which purportedly is seeking to serve the poorest, cannot deliver donated drugs of proven efficacy that can eliminate disease and provide multiple benefits at the annual cost of cents rather than dollars, it is difficult to see that community rising to the greater and costlier challenges. This is a tipping point for the diseases of the poorest people.”  I hope that Dr. Hotez and the NTDGN can be more specific in what needs to be done and how to do and get started.

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