Neglected Tropical Disease?

So what is a neglected tropical disease, and why did UK aid announce new support for them in 2019?

To explain let’s start with a normal tropical disease that you will have heard about, Malaria. In the capital of Chad, N'djamena it is the wet season, the rains fall over 3 or 4 months filling the River Chari with life giving water that in its turn fills lake Chad and enables this otherwise arid zone of Sahel to be fertile and habitable. The water also collects in puddles and ponds and the mosquitos multiply and the same rains also give rise to the deadly malaria season. When we worked at the Guinebor II hospital we recorded the annual change between the months at the end of the dry season April and May with 20 positive malaria tests a month and September October with 600 positive tests. Overall malaria causes about 15000 deaths a year in Chad, mainly in children under 5 years of age. Malaria is acknowledged as a major health problem in sub-Saharan Africa and in Chad there has been for many years a national program of prevention with bed nets and free treatment, thus it is not a neglected tropical disease.

In Bardai, in the mid Saharan Tibesti mountains it only rains once or twice a year and, due to the fact that there is therefore little free-standing water, there are few if any mosquitos. Even the few that there are would have difficulty maturing malaria parasites as it is often too cold or even too hot for that to happen. The few cases of malaria that we see are amongst travellers who have bought the infection with them across the desert, in the same way as someone can have malaria in the UK after a holiday abroad.

 

However, there is another disease that is transmitted by an appropriately named sand fly that does not need pools of water to reproduce. It also kills children under 5 years of age and last year we treated 63 cases. It is fatal without treatment nearly 100% of cases die a slow death due to anaemia, bleeding, malnutrition and infection. The disease is called visceral leishmaniasis, you may or may not have heard of it. It is classified as a neglected tropical disease due to the fact that it kills a comparatively  small number of people and those in developing countries and so has not received the attention that it merited, and yet it is still a major problem communites affected like the Tibesti.

In order to understand better, lets look at death rates due to Covid in the UK. Around 2000 people have died in every million of the UK population, the young are usually less severely ill and it is mainly but not exclusively the elderly and those with underlying health conditions who have been most affected. We have organised fundamental changes in the way society functions, quarantining, lock downs, social distancing and mask wearing and have committed billions of pounds to find a vaccine and a cure. This has been a once in a generation, or even once in a century event.

Last year by treating 63 cases of leishmaniasis we treated at a rate of about 1400 per million of population. All had a fatal illness without treatment, that occurs every year, and yet treatment here only began 3 years ago. Assuming that we are not yet diagnosing and treating all the cases in this mountainous region the death rates up till 3 years ago when our treatment programme started was also about 2000 per million, (but there are only 45000 Teda). This time it is children under 5 years and not the elderly who are most affected. Imagine a similar scenario with an illness killing children, that many children in a small town of 45000 people in the UK, what sort of response would we have made?

To its credit, the British government has been at the forefront of the fight against neglected tropical diseases paying for research into better and simpler diagnostic tests and less toxic more effective treatments. It also has been supporting the treatment programmes in East Africa, where Sudan and Kenya have seen very large epidemics of visceral leishmaniasis, and tens of thousands of lives have been saved every year. 

We initially diagnosed in 2018, two typical cases that died due to lack of availability of treatment in Chad. It was the cause of much discussion in the Teda community and a  year later the Ministry of Health started to supply our hospital with free drugs (in 2019). A church in Birmingham supplied us with free tests so that we could be surer of our diagnosis and pick up earlier cases. Once we had the supplies we were amazed at the number of cases that we were able to treat.

Our results caught the attention of World Health Organisations Neglected Tropical Diseases unit, and they wanted confirmation that Chad was an endemic country. At their request we took specimens of blood from our patients with us on the plane to N'jamena  and they sent them or leishmaniasis PCR in Madrid. The results definitively confirm that the disease is in Chad. A national programme with support from the WHO is being set up and will also look for cases in other parts of the country. 

Free treatment and testing is essential for a successful program. If we were to buy the branded medicine Glucantime® (Meglumine antimoniate) Sanofi-Aventis, it would cost us over £250 to treat a small child. In N'djamena I treated a small number of adults whilst working at the Guinebor II hospital at over £500 a case. That is about a monthly salary for a doctor or 4 times the minimum monthly employed wage, and an impossible sum for most Chadians. Thankfully the generic medicines provided by the government are less expensive and what’s more provided free to the population.

The hospital pharmacist with part of a recent delivery of drugs and tests for the next year.

And so, along with Royal Society of Tropical Medicine and Hygiene, I am deeply saddened by the 4 billion pound UK Aid cuts recently narrowly voted through in the face of cross party opposition including all the previous five living Prime Ministers, Theresa May, David Cameron, Gordon Brown, Tony Blair and John Major. As a result this year the  Neglected Tropical Disease budget is to be cut by 150 million pounds and one of the expected results is that funding for free treatment of Leishmaniasis the East Africa will no longer be provided by UK Aid, this will cost thousands of  lives and in my opinion diminish the standing of Britain in the world.

At the same time the Royal Navy is impressing the world with its newest ship, an aircraft carrier, on its maiden operational voyage through the Mediterranean, Suez Canal and now around the Far East. It will eventually have a full complement of 24 F-35 Lightning II fighter bombers at the cost of 190 million pounds for each plane. One plane costs more than the cut in the Neglected Tropical Diseases budget. The Queen Elizabeth aircraft carrier itself cost about 4 billion pounds, which happens to be the total UK aid cuts for this year. Perhaps the government hopes to re-define our post Brexit reputation as a leading world military power rather than as a leading compassionate world developmental power. I hope that this is not the case, and that the treatment of neglected tropical diseases will not become a forgotten part of British policy.

The prophet Micah spoke of a future time when God will act:

“He shall judge between the nations,

   and shall arbitrate for many peoples;

they shall beat their swords into ploughshares, 

and their spears into pruning hooks;

nation shall not lift up sword against nation,

neither shall they learn war anymore;

but they shall sit under their own vines and under their own fig trees,

and no-one shall make them afraid:”

                                                                                       (NRSV)

The prophecy is not only something that we should hope for, but also be something that we aspire to and work towards. May we all play our part in bringing it to pass both in the UK and throughout the world. Re-instating the UK Neglected Tropical Disease budget would be a good place to start. 

Crumbs from your table

At the start of this millennium the HIV pandemic was largely under control in the west but was still wreaking havoc in sub-Saharan Africa. The number of cases were rising at our TB hospital in Macenta, Guinea and there was little that we could do apart from palliative care. The required drugs would have cost over $5000 per patient per year and were way beyond the budget of a small NGO to pay.  

Amazingly all that changed after  a long fight between activists and pharmaceutical companies generic medicines became increasingly affordable for low income country programs but external funding was still required. Bono, from U2, had visited a hospice in Uganda where patients were sleeping and eventually dying three in a bed , the sisters who served there were simply overwhelmed, what could he do to help?

He recounted to Q magazine, 

“I went to speak to Christian fundamentalist groups in America to convince them to give money to fight AIDS in Africa. It was like trying to get blood from a stone.”

 His frustration and anger pours out in the lyrics to the song

Where you live should not decide

Whether you live or whether you die

Three to a bed Sister Anne she said

Dignity passes by ...

You speak of signs and wonders

I need something other

I would believe if I was able

But I'm waiting on the crumbs from your table ...

Thankfully HIV is now a treatable disease in sub-Saharan Africa. There are still hurdles of societal prejudice and shame to be overcome, but even in remote places like Bardai where we practice medicine in a Ministry of Health hospital, we have a good supply of tests and triple therapy available free. Unlike other parts of Africa HIV/AIDS is not the major health problem here but for those individuals that need treatment for themselves or to protect partners or their as yet unborn child, the medicines are still essential.

Some of the same frustration that Bono sang about is building now around the response to Covid-19. The Peoples Vaccine Alliance have spoken of the weak efforts to vaccinate lower and middle income countries with charitable donations as crumbs from the table. Last week the WHO was talking of the disparity between the high vaccination rates in the rich nations (56% of the UK population fully vaccinated) and the 1.5% of the African population. It has been suggested that as a minimum, all medical personnel and vulnerable people throughout the world should be vaccinated before we start administering 3rd booster doses of vaccines in the rich nations. Sadly it seems likely that this call for some sort of equity will  be ignored and the government will continue to talk of its financial support for COVAX and vaccine donations from the UK, rather than addressing fundamental questions of vaccine equity.

This week the UK has at last started to send 9 million Astra Zeneca vaccine doses manufactured in the UK overseas. The first of 30 million doses promised at the G7 summit are to be delivered by the end of this year, with a further 70 million by June next year. That sounds a lot but it is only enough to vaccinate 50 million people. The problem is that we live on a planet with a population of 7 billion, so that is  only enough to vaccinate a mere  0.7 % of the world population. About half of doses announced will be given to COVAX and will be distributed according to an equitable plan, the other half will be given directly as a gift from the UK as the government engages in ‘vaccine diplomacy’ supporting friendly nations with whom we have or aspire to closer ties. All  this amounts to crumbs from the table, albeit gratefully received. 

The Foreign Secretary, who along with his advisors decides where the doses should go, said “ We are doing this to help the most vulnerable, but also because we know we won’t be safe until everyone is safe”. Meanwhile at the same time the UK and Germany are lobbying the  World Trade Organisation’s against a TRIPS (patents) waiver, this blocking the historic move, supported by a majority of nations including France and the USA, that would allow scaling up of manufacturing across the world, and the production  of the billions of doses needed in a quicker and less costly manner. Crumbs from the table charity is being used as an excuse not to talk about and implement just policies such as the TRIPS waiver that would be the real solution to the problem of vaccine equity.

It is not unknown for the government to selectively quote the bible when speaking, so  if reading the Bible is going to inform government policy perhaps ministers should read about some biblical  principles in story form starting with the rich man and Lazarus in Luke 16:19-31. It is quite a shocking story, both for a first century and a contemporary 3rd millennium  audience, and it speaks equally well to economic systems and individuals. 

Meanwhile the reproach from Bono about injustice and indifference towards HIV/AIDS remains relevant during the current  pandemic. Whether we like the music or not the words cut us to our hearts.

Where you live should not decide

Whether you live or whether you die

Three to a bed Sister Anne she said

Dignity passes by ...

You speak of signs and wonders

I need something other

I would believe if I was able

But I'm waiting on the crumbs from your table ...