NTD TD

While viewing audience for the upcoming Souper-duper Bowl is likely to exceed 100 million, 16 times more people are afflicted with the world’s most disabling and disfiguring diseases, the “neglected tropical diseases” (NTDs).  These 1.6 billon and another 2 billion people at risk of infection are the target audience for last Monday’s “Uniting to Combat NTDs” meeting, a notable convocation of representatives of pharma companies, health agencies, disease advocacy groups, foundations, and governments (about 20 in all) who agreed to participate in the WHO-guided effort to substantially eliminate the NTDs by 2020 (Press release at FierceBiotech).  NTDs (ascariasis, hookworm infection, trichuriasis, lymphatic filariasis, onchocerciasis, dracunculiasis, schistosomiasis, Chagas disease, human African trypanosomiasis [HAT], leishmaniasis, Buruli ulcer, leprosy, and trachoma) are diseases of the impoverished, have low mortality but high morbidity with long periods of suffering and often a lifetime of disablement, and hence have a devastating effect on societies in the endemic areas (Kaiser Fnd Fact Sheet).  Fortunately, most can be treated effectively by inexpensive drugs.  But despite large qualities of donated drugs, foundation funding, advocacy and NGO participation, and several notable successes (e.g., 670 million receiving preventive treatments annually, elimination of onchocerciasis in West Africa, and 60% decrease in the incidence of HAT), according to the WHO (WHO 2010 Report) and critics (e.g., Molyneux 2010), the neglected diseases were still neglected.  (Additional background is in my previous post, “Brother, Can You Spare a Dime (or Five)?”  2/24/11.)

The attendees of the meeting agreed to WHO’s playbook, “Accelerating Work to Overcome the Global Impact of Neglected Tropical Diseases” (Roadmap for Implementation), but how will they score?  Here’s my play-by-play:

Expanding current drug treatment:  ten pharma companies (Bayer, Eisai, Gilead, GlaxoSmithKline, Johnson and Johnson, Merck and Co., Merck KgA, Novartis, Pfizer, and Sanofi) will expand their donation of 14 drugs in quantities sufficient to treat almost everyone who needs it through 2020.  The pharma industry trade group, the International Federation of Pharmaceutical Manufacturers and Associations, stated that the donations will amount to 1.4 billion doses per year, a substantial quantity (IFPMA press release).  The cost to the companies will be about $70 million per year, excluding opportunity costs, based on my guess of a $0.05 per tablet cost-of-goods (Wikipedia article on generic drugs).  A cynic will note that this is less than 2% of the $4.3 billion the multinational pharma companies spend each year on advertising in the US (FiercePharma article), including those 30-second spots for drugs for erectile dysfunction (not an NTD) we’ll enjoy when not watching the action during Sunday’s game.

Development of new treatments:  11 pharma companies will agree to provide the leading NTD non-profit R and D group, the Drugs for Neglected Disease Initiative (DNDi), access to compounds and data for testing for activity against the NTDs, and DNDi and several companies will continue their collaborations on possible treatment.  The companies gave no specific dollar amount for their commitment to spending on NTD research, although the GFinder survey, which tracks global health spending, reported that companies’ spending on both internal and external NTD R and D was about $400 million in 2009 (GFinder 2010 report) or about 0.5% of the total $70 billion pharma R and D spend (Reuters article), not strong offense.  For a critique of the WHO approach as being heavy on treatment and light on research, see Patrick Adams’ posting of last November (Tropika blog).

Funding:  the ever-generous Gates Foundation pledged to kick in another $386 million and the USAID ($90 million for FY 2012) and UK’s DFID ($200 million through 2015) ponied up as did the Lion’s Club International, the government of the United Arab Emirates, and Mundo Sano, a privately-financed NTD institute in Argentina.  More money is great; however, I note that, according to an NTD researcher and advocate (Molyneux 2010), only 0.6% of all international health development assistance is aimed at NTDs so one could argue the funding is not in proportion to their impact and more is justified.

On the ground:  the biggest challenge in tackling the NTDs has been operational.  Weak public health systems have typically been by-passed and marginalized by the aid groups, so critics have questioned the long-term effect and benefit of the NTD effort (e.g., Morris 2010).  The meeting’s most promising announcements were specific goals for NTD control and elimination set by the government of Mozambique and the statements  by the governments of Brazil, Tanzania, and Bangladesh that they will implement of plans to control and eliminate NTDs in their countries.  But as far as I could find, the Roadmap has no mechanism for reviewing, monitoring, supporting, or participating in these plans or the plans of the other 70 or so NTD-endemic countries.  According to the meeting press release, “partners will follow collective progress through a scorecard that will regularly and formally track progress including whether participating organizations are meeting their supply, research, funding and implementation commitments,” but the process is not provided in the Roadmap which defers to specifics given in an unpublished WHO report of an April 2011 meeting (Roadmap, page 2).  Ultimately, public health is the responsibility of the governments and without some mechanism for monitoring performance in providing treatments, vector control, and improvements to water and sanitation, governments will not be accountable and the goal of NTD eradication will not be met.  In response to the meeting, the well-respected global health group, Médecins Sans Frontières, cheered for its intent but was concerned WHO was underplaying the challenges, especially for Chagas disease, sleeping sickness, and leishmaniasis, noting more support for in-country programs and product development is needed (MFS briefing).

My half-time analysis:  WHO’s team leads the NTDs by a field goal, but it’s going to be a tough second half.  It should up its game and not be allowed to punt.

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