(7 years, 8 months ago)
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Baroness Hayman
To ask Her Majesty’s Government what is their assessment of progress made in combating neglected tropical diseases since the London Declaration made in January 2012.
Baroness Hayman (CB)
My Lords, tonight’s debate has been an extremely movable feast in terms of dates, times and length of speeches. However, at last, we are here and I am delighted to introduce a debate which has become, over the past five years, a standing item in the parliamentary calendar. I am extremely grateful to colleagues here tonight for their commitment to a subject which, before the London declaration of 2012, was very much a minority interest even among those who focused on health in the developing world.
Tonight I hope that we can do two things: first, that we can look back and record achievements in combating the 18 bacterial, viral and parasitic diseases brigaded in the WHO’s category of neglected tropical diseases affecting more than 1 billion people in 149 countries across the world, and that we can also look forward and recognise the major challenges that remain if we are to meet the targets set in 2012 in the WHO’s 2020 NTD road map and in the London declaration of the same year.
I know that colleagues are well aware of the toll that these diseases take on individuals and on human and economic development in the countries in which they live. These diseases result not only in half a million deaths each year; they also cause chronic disability, stigma and long-term ill health. They affect children’s development and pregnancy outcomes. They are the diseases of poverty and in themselves they perpetuate that poverty. As Margaret Chan, the director of the WHO, put it in that organisation’s latest report:
“NTDs thrive under conditions of poverty and filth. They tend to cluster together in places where housing is sub-standard, drinking water is unsafe, sanitation is poor, access to healthcare is limited or non-existent, and insect vectors are constant household and agricultural companions”.
Unsurprisingly, we think of NTDs primarily as diseases of the developing world, and that of course is where they take their highest toll. But poverty is not confined to those who live in poor countries, and cases of NTDs are found among the poor of even the wealthiest countries. In North America, there has been the emergence of Chagas disease in several southern states. In Europe, between 2007 and 2015 we saw outbreaks of chikungunya in Italy, France and Spain, of dengue in Portugal, of leishmaniasis in Greece and of schistosomiasis in Corsica.
The causes of these cases of emergence and re-emergence are not only poverty, but climate change and mass human migrations linked to the hundreds and thousands of people fleeing conflicts in Libya, Syria and Iraq. In Syria cutaneous leishmaniasis has reached hyper-epidemic proportions due to breakdowns in health systems and a lack of access to essential medicine, with tens of thousands of new cases annually. There is a real danger of introducing or reintroducing NTDs endemic to the Middle East and north Africa to Europe and beyond. All this highlights the global challenge of NTDs and emphasises the need to make progress in tackling these diseases of poverty in our interconnected world if we are to achieve the “ensuring healthy lives for all” sustainable development goal.
In the five years since the London declaration, we have made considerable progress. The bringing together of Governments, pharmaceutical companies, NGOs and researchers, scientists and doctors, has had profound results. Increased donations of essential medicines, targeted funding by international development agencies, private foundations and the domestic financing of NTD programmes by endemic countries are drastically improving the quality of life of millions worldwide. Almost 1 billion people were treated in 2015 alone. Thanks to the donations of several major pharmaceutical companies, billions of doses of drugs have been donated in the past five years so that by last year around 50 treatments were being delivered by mass drug administration programmes every second of the day. UK aid and the work of British institutions, NGOs and partnerships like the Liverpool School of Tropical Medicine, the Schistosomiasis Control Initiative, Sightsavers and the London Centre for Neglected Tropical Disease Research are all playing a critical role in implementing prevention and treatment strategies, and in generating evidence from operational and scientific research to inform efforts to achieve the 2020 WHO targets. Since 2013, four countries in central America have all eliminated river blindness and the misery that the disease brings, and last year both the Maldives and Sri Lanka were certified free of lymphatic filariasis. Great progress has been made and I am happy to pay tribute to the role that the UK Government have played both in their original support for the London declaration and through their ongoing leadership and financial contributions.
But we have to recognise that there are significant challenges ahead and “steady as she goes” will not deliver the targets set, particularly for soil-transmitted helminths. Mass drug administrations will need supporting infrastructure such as water and sanitation projects, additional interventions, including new medicines, and in particular, as I raised in the debate last year, new vaccines. We were then all anxious about Zika and focused on the need for prevention rather than cure. One of my questions for the Minister is whether DfID is considering broadening the R&D focus on NTDs to explore potential vaccines, given the research evidence that suggests several diseases such as schistosomiasis and soil-transmitted helminths will not be eliminated by mass drug administration alone.
In addition to vaccines, we need to continue searching for better tools across the board. We have new mapping tools and we understand better the burden of disease, but we will have to continue improving diagnostics, such as the new rapid diagnostic test, funded by DfID, for sleeping sickness. We will need to improve our strategies on vector control and, as in most areas of combating poverty, to do more on the education and empowerment of women and girls, which has a demonstrable effect on sustained access to clean water, sanitation and hygiene. Sufficient and safe access to water in turn helps to combat NTDs such as trachoma, schistosomiasis and soil-transmitted helminths.
While most of the targets of both the WHO and the London declaration understandably focus on interrupting transmission and infection cycles, we have to be aware that NTDs cause severe morbidity and lifelong disabling conditions such as blindness and disfigurement, which in turn lead to stigma and exclusion. So resources should also be directed towards improving the quality of life for people suffering from the consequences of these diseases and integrating services into existing health systems and ongoing NTD programmes. I hope the Minister can give us some information about the Government’s plans for NTD spending and how the NTD portion of the Ross fund will be managed and allocated, as this portfolio will be key to the delivery of UK aid to NTDs.
Next month, the WHO, Uniting to Combat NTDs and the NTD community will host a summit in Geneva to mark the fifth anniversary of the road map and declaration, and to plan for the future control, elimination and eradication of NTDs. I hope the Minister will make clear the Government’s commitment to that summit; that we will have high-level political representation at that meeting; and that we will have a commitment to further funding and continuing the task set five years ago. That meeting is an opportunity for us to continue our leadership with other donors in the philanthropic world and other national donors, and to work with the Governments of endemic countries to come together and once again commit to consigning these diseases of poverty to history.
Baroness Buscombe (Con)
My Lords, all noble Lords may speak for five minutes.
Lord Stone of Blackheath (Lab)
My Lords, I declare an interest as a member of the advisory board of the Schistosomiasis Control Initiative at Imperial College. I am on the board only because I am one of the few people who can say schistosomiasis. No wonder it is neglected. I have asked them to rebrand it. I am also on the board because I am a businessman and retailer. I will focus on the enormous cost/benefit of SCI’s work and the huge return on capital employed. It effectively controls schistosomiasis across 11 countries in Africa at a cost for each child treated of 30p a year.
This is one of the most cost-effective public health programmes ever. Let us look at the scale: more than 91 million treatments have already been delivered, with funding largely from DfID. More than 200 million treatments will be delivered by 2019, half of them to girls and women. The worms are killed in children by just one safe and effective treatment; anaemia and malnutrition are reduced; the healthier children will then go on to attend school, and in the longer term, free from serious organ damage, they can contribute to their society for life.
So let us look at the maths. Disability-adjusted life years, or DALYs, due to schistosomiasis cost Africa hugely. Treated youths will be able to work for years to come. For every million who can work, even at just $1 a day, it is like $400 million of aid for Africa every year for ever. Other business people see this immediately as a must. Merck and GlaxoSmithKline donate tens of millions of praziquantel and albendazole tablets every year. The “effective altruism” movement has highly recommended our project. Philanthropists such as Luke Ding are there year after year donating large sums through Prism the Gift Fund—where I declare a trusteeship. The Bill & Melinda Gates Foundation has supported us hugely over the long term. Just recently, Dustin Moskovitz and Cari Tuna, through their charity, Good Ventures, have made one of the largest gifts ever received to Imperial College for this cause.
In addition to controlling schistosomiasis, we could eliminate it in most countries across Africa by 2030. Elimination would pay back enormously in increased prosperity across Africa and the world. To this end, and to break down the silos, SCI is part of a global network which, together with DfID investments, is working to strengthen local health systems. It is working with the World Health Organization; with Oxfam’s water, sanitation and hygiene programme—or WASH; with the Natural History Museum in a partnership studying the larvae, worms and snails that cause schistosomiasis; and with the noble Lord, Lord Trees, and the Royal College of Veterinary Surgeons.
Schistosomiasis elimination is not only the right thing to do but would be massively cost effective. Perhaps the Minister would like to meet those expert practitioners at the Schistosomiasis Control Initiative at Imperial College to discuss the cost effectiveness of all this and a brighter future for all.
Baroness Northover (LD)
My Lords, I thank the noble Baroness, Lady Hayman, for securing this debate and, as ever, for opening it so effectively. I declare an interest: I am a trustee of the Malaria Consortium, a position that I took over from the noble Baroness.
Baroness Hayman
I shall not take up more time, but I did not declare my interests at the beginning of my speech, which I should have done. I therefore do so now: they are as recorded in the register.
Baroness Northover
I remember the huge excitement of the London meeting in 2012, when the UK, by that stage moving towards spending 0.7% of GNI on aid, as so long promised, was able to increase its commitment on neglected tropical diseases so substantially, by an additional £195 million. I was proud to be part of DfID’s ministerial team at the time and recall the amazing briefings that I was given by committed experts not only from the department but from the London School of Hygiene & Tropical Medicine—including on how you pronounce the names of all these various diseases.
As the noble Baroness has pointed out, NTDs affect more than 1.3 billion people worldwide and cause half a million deaths each year. They cause chronic disability, disfigurement, stigma and ill health. They disproportionately affect the poor and marginalised.
It is vital for delivering the SDGs that we address the NTDs. Of course, there is goal 3 on healthy lives, but it is much more than that. The SDGs aim to eliminate extreme poverty while leaving no one behind. It is the poorest and those with disabilities who are so often left behind. Tackling these diseases is part of the overall strategy of all the SDGs. In doing so, we need to focus on research, and here the London School of Hygiene & Tropical Medicine and the Liverpool School of Tropical Medicine have been so important, and the UK has had such strengths.
We need to make sure that treatments and preventive measures, such as vaccines, are coming forward and that we get them where they are needed. We need also to ensure that we have adequate surveillance. This is, of course, vital for understanding a country’s true burden of disease, as well as for securing and achieving intervention, detecting the last cases and, when and if we are in that fortunate position, making sure that there is no resurgence. I urge the Government to use their position as a leader in this area to encourage others to increase their own support. The noble Baroness, Lady Hayman, mentioned the upcoming summit in Geneva towards the end of April as a key opportunity for this. I, too, ask whether the Secretary of State will attend.
Like the noble Baroness, Lady Hayman, I want to ask about the Government’s Ross fund, announced by the former Chancellor in the autumn of 2015. It seems an absolute age ago, but it included £200 million to tackle NTDs. As far as I know, there have been no announcements yet relating to NTDs. Can the Minster clarify what is happening? It has also been flagged to those of us speaking today that leprosy remains a neglected disease, where others are no longer so neglected. Will the Minister comment on this?
I come now to the eradication of certain NTDs: it is fantastic that we have reached that point. We had the wonderful visit from President Carter last year—in 1986, Guinea worm disease affected 3.5 million people; now, it is almost eradicated. President Carter said that he hoped to outlast the last Guinea worm. I am delighted that the former President is still with us and I want to ask about those last Guinea worms. Have we almost reached that point and do we have any information on other NTDs which are on their way out?
Finally and most importantly, what assessment has DfID made of the effect of Brexit in this area? We know that scientists working in the United Kingdom come from many different parts of the world, but especially from the EU. What are we doing to encourage them to stay? How can we make sure that they know that the UK’s leadership in this area, as in many others, depends so much on them and that we are very grateful to them? I look forward to the Minister’s responses in this vital area, which is so important for the health of the poorest around the world, and where the United Kingdom has such a proud record.
Baroness Chalker of Wallasey (Con)
My Lords, I congratulate my noble friend Lady Hayman on what she said at the commencement of this special debate. I endorse everything she said 100%. We have had many battles in the past but on this issue we agree completely. I have many interests in this field but I want to focus mainly, as a long-term supporter and as a patron of WaterAid, on the critical role of water and sanitation in helping to defeat NTDs.
First, I pay tribute to Barbara Frost, the chief executive of WaterAid, who is to retire in the coming months after more than 10 notable years as its head. Much of what has come into the WASH programme and into other considerations, could not have occurred but for her leadership and her team’s work and we should put on record our thanks to her. She has been totally relentless in what she has done to get increased action to supply clean water and basic sanitation, not just through our own department’s programme, which has been notable, but also in other countries’ programmes which were not as well led as the water and sanitation programmes led by DfID in this country.
One question I want to ask my noble friend is whether the Ross fund can be extended to some of the further work that needs to be done to get better water engineering, which is essential to the supply of clean water. It seems to me that we know what needs to be done, but the resources are very often at the end of the pipe, rather than at the beginning of the process. I believe that we should be paying more attention to this.
There is one further area of work that I hope DfID will undertake. We are doing very well indeed, with the help of the London School of Hygiene & Tropical Medicine, where I was proud to be the chairman for eight years, and the Liverpool School of Tropical Medicine, where I was on the council. But we are not doing enough on basic health training for doctors in countries where the NTDs are still thriving. We need to focus, with the royal colleges, on better training in-country for the doctors of the countries that suffer the NTDs. We are doing insufficient work in that field. Much as we try, it is certainly not reaching many of the doctors who are practising, when it is accepted knowledge in this country and many other developed countries.
I do not wish to repeat what the noble Baroness, Lady Northover, or anyone else in the debate said, but I believe that we should have not just an annual repeat of our efforts but more frequent debates on these vital subjects. Healthy societies in the developing world help the education of the young in the developing world. They cannot have those healthy societies if they continue to have the amount of illness caused by NTDs and, indeed, dirty water. I hope my noble friend will be able to give us some hope of more activity.
The Lord Bishop of St Albans
My Lords, I, too, thank the noble Baroness, Lady Hayman, for introducing the debate. It is good to pause and reflect on the extraordinary progress that has been made, as well as the salutary thought of just how much more needs to be done. I am not a medic and do not want to engage in the medical aspect of this, but I want to make one, very brief point: the need to adopt clear protocols and joined-up approaches if we are going to be really effective in combating neglected tropical diseases.
I will illustrate this with the Ebola crisis in Sierra Leone, which broke out in 2014. At that point, medical teams were deployed from various parts of the world in the most extraordinary way. They adopted various measures for containment and treatment that were not always understood or appreciated by many local people. Indeed, it was very frightening, and the first-hand accounts of these teams by local people showed that it was quite shocking for many of them. In some areas there was actually hostility to what appeared to be draconian measures—made for the very best medical reasons—some of which were confronting local customs or traditions that the local population held dear.
Of course, community leaders have a role in education and communication, yet it took quite a long time to realise the role that faith leaders could play in mobilising and educating local people. Faith communities were to be found in virtually every community. They had regular meetings. They had resources, networks and communication. In Sierra Leone, respected Christian and Muslim leaders were eventually recognised as allies in challenging some of the myths and misinformation that were around. It was as important as the medical interventions that people had to want to collaborate. It was about local empowerment as well as medicine. That provided an important avenue by which to get life-saving advice about protection and prevention out to the community. Then there was the question of preventing and confronting the stigmatisation of the survivors, which was a profound problem.
This sort of engagement is an excellent example of what, at their best, worldwide religious networks such as the Anglican communion can do so effectively. Of course we are involved in raising money for water projects. A number of my churches proudly have signs up saying they have adopted toilets in other countries, and so on. These are the sorts of things that are happening because of the links right across the world. This is where we can act as a bridge between local people and outside agencies, often in hard-to-reach areas.
This is especially important for countries or areas which are in conflict or at war. At such times, NGOs can find it very difficult to deploy anybody and if war breaks out they have to withdraw their staff, rightly, to protect them—there is not much choice if you employ people from elsewhere. But unlike the NGOs, the churches will be there before, during and after the conflict or disaster and their clergy tend to be local community leaders, rather than outsiders. Very often it is local parishes or the diocese which run the schools, clinics and hospitals.
My simple plea to DfID, NGOs and all parties involved in this area is to bear in mind the vital need to get everybody round the table at the earliest stage to think about the cultural traditions and local faith issues if we are really to mobilise all people in delivering good health advice, some of which is preventive. This is so that we do not just look at the medical challenges but work with all the networks on the ground to address the social and religious contexts of those communities which are suffering so from these terrible diseases.
Lord Rea (Lab)
My Lords, the noble Baroness, Lady Hayman, deserves our thanks for asking this Question and for her persistence with NTDs. She makes sure that these debilitating diseases are not neglected, at least in your Lordships’ House. Because these diseases are now mostly treatable, the accent up to now has been on medication, with less emphasis on prevention. But the underlying causal factors will allow the diseases to return, requiring repeated medication if they are not addressed. An example of this is onchocerciasis, or river blindness, where it is extremely difficult to eliminate the insect vector—a tiny blackfly. Repeated courses to treat river blindness are often necessary.
Tackling the causes, as at least two if not three previous speakers have said, requires the introduction of clean water, sanitation, improved hygiene and vector control where possible. As my noble friend Lord Stone said, this is encapsulated in the acronym WASH, which is now very much part of the NTD programmes of the WHO, DfID and other agencies. Of course, WASH plays a big part in the control of other diseases and the elimination of extreme poverty. We should remember that the provision of clean water and sanitation was and still is a basic part of all public health, dating from the time of our great-grandfathers in the 19th and early 20th centuries. Much earlier, water-borne sanitation was used by the ancient Romans, but with the decline and fall sanitation was also lost. Can the noble Lord, Lord Bates, give us a report on international progress with WASH programmes across the board and DfID’s part in them?
I also repeat the request of the noble Baroness, Lady Hayman, for information about the development of new vaccines for NTDs. In particular, I wonder whether we are having success in developing new point-of-care rapid diagnostic tests. These can greatly increase the cost-effectiveness of treatment programmes because it is possible to identify people who are not carrying the disease.
As a further point, the Leprosy Mission is concerned that not enough is being done to control and eradicate that stigmatising neglected disease. There are still pockets around the world where it is not eliminated. Can the Minister say whether DfID’s role in this will continue—it already plays a certain part—and, I hope, be stepped up?
Finally, I follow other speakers in hoping the Minister can assure us that the UK’s contribution to the international collaboration on NTDs will continue to be adequately funded, Brexit or not, and help to achieve the UN’s sustainable development goals.
Baroness Barker (LD)
My Lords, I thank the noble Baroness, Lady Hayman, not just for today’s debate but for the succession of world-leading scientists who she and Jeremy Lefroy bring into Parliament week after week so that some of us can begin to understand the complex science about which we are speaking tonight. Having listened to those scientists for over a year, I now understand that we are talking about three main types of disease when we talk about neglected tropical diseases. Those caused by worms and flukes are largely treated by very simple population management methods. Those which are vector-borne are much more complicated and need treatment in hospital; malaria is the classic example. The third group is made up of the very highly contagious epidemics which hit a population with a much more profound effect than they would do here when that population is, as noble Lords have said, living in poverty and without access to basic medicine.
The approaches to all three of these disease groups are quite distinct, and the hazards that they pose are quite different. They are also all happening, worryingly, against the background of multidrug resistance, for example for TB and malaria, which is probably the equivalent of climate change in medicine and something that we should be very focused on and frightened of. But a very important point is that the same institutions and scientists that work on drug resistance mechanisms are the same scientists who work on the mechanism behind NTDs. So the science is interconnected, and I want to talk about maintaining that science base.
Other noble Lords have spoken about the heritage that we have from our colonial past in the schools of tropical medicine in London and Liverpool, and it is time that we repaid what we took from the world, by ensuring that those institutions continue to work to provide the basic science to support pharmaceutical companies to take forward new compounds into development and clinical trials and on towards new medicines. In that, international funding from Governments, including for example from DfID, is really important. It does two different things: humanitarian aid, which is very important, but also funding for long-term scientific and medical development. That is the stuff which the public do not really see and which is therefore much more vulnerable to cuts. I hope the Minister might be able to assure the House that DfID will continue to play its leading role in humanitarian funding but will also not take its foot off the pedal in terms of funding the scientific research.
Other noble Lords have spoken about the fact that it is always the marginalised people in these countries who suffer the most, but I want to raise one other issue with the Minister. The disengagement from global health by the USA under the Trump Administration will have a huge impact on in-country programmes, particularly in Africa, where many institutions such as hospitals and universities are very dependent on American support for funding both their staff and the equipment and buildings. In Ethiopia, for example, the whole of the medical school expansion programme is funded from the USA via the World Bank. It remains to be seen whether organisations such as the Bill & Melinda Gates Foundation, the Carter Center and the Clinton Foundation can step up and fill that gap. US government institutions such as the CDC and American universities such as Johns Hopkins, we think, may also be forced to stand back.
It is really important when we are trying to deal with outbreaks of these diseases around the world that there is a standing body of people in countries who have the scientific expertise to bring about a response. Will DfID perhaps switch its funding, in light of the Americans’ withdrawal of funding from certain sexual and reproductive health programmes, to ensure that funding for those programmes continues? Will the Government also press the Trump Administration, who have less objection to work on NTDs, to place some of the money that they have withdrawn from the other programmes into programmes supporting the science and treatment of neglected tropical diseases?
Lord Alton of Liverpool (CB)
My Lords, it is a great pleasure to support my noble friend Lady Hayman and salute her dogged persistence in raising the issue of rare and neglected tropical diseases. In doing so, I should mention that I am a vice-president of the Liverpool School of Tropical Medicine and have been associated with the school in one way or another for the best part of 40 years. I particularly pay tribute to Professor Janet Hemingway, whose brilliant leadership has ensured that the school has maintained its world-class status, and the remarkable Professor David Molyneux, who ranks as one of the foremost global authorities on neglected tropical diseases.
The Liverpool school has been involved with NTDs since its creation in 1898, and has been responsible for many of the ground-breaking discoveries in the field. A school staff member was among the small group who coined the term “NTDs” with the World Health Organization in 2004-05. I should like to use my brief contribution to this evening’s debate to shine a light on the school’s amazing work and to encourage the noble Lord, Lord Bates, to consider what extra assistance might be given.
Let me give the House just some examples of the ground-breaking work in which the Liverpool school has been involved in the past decade. With DfID support, the lymphatic filariasis programme continues to make a real impact on poor people in 12 countries, having assisted ministries of health to deliver 200 million drug doses since 2009. As a result, in Malawi, for instance, transmission of filariasis has stopped. The Liverpool school and the London Centre for Neglected Tropical Diseases have expanded their commitment to those who remain disabled through the disease, recognising the tandem aims of stopping transmission and, as my noble friend Lady Hayman said, reducing chronic disablement. The school has been identifying patients, training surgeons to alleviate this stigmatising male genital disease, and demonstrating the benefits of surgery to those who are disabled.
Secondly, LSTM researchers are at the forefront of new and exciting approaches to mapping neglected tropical diseases using remote sensing technologies, mobile smartphone technologies for detecting NTD cases, patient identification and mapping diseases. I should be grateful if the Minister could tell us what study DfID has made of the use of such technologies.
Thirdly, with support from the Bill and Melinda Gates Foundation, the school has developed the use of the antibiotic doxycycline and, with industrial partners, has developed a new drug ready for clinical trials to treat river blindness and elephantiasis.
Fourthly, the school’s staff are at the forefront of research on insecticide resistance—a major and increasing problem in the fight against malaria, but now also against Zika. This work has major policy impacts in all insect-transmitted diseases. The LSTM is a key policy adviser to the World Health Organization and is working on Zika projects to assist control. Perhaps the Minister could say a word about that too.
Fifthly, the school leads the way in snake-bite research. Snake-bite is a massively underestimated problem globally. I was amazed to be told that at least 100,000 deaths per year are attributable to a condition that often leads to amputation. Africa is in dire need of anti-venoms, as the major manufacturer has ceased production. The LTSM is seeking to develop new products which are multivalent, do not need to be in cold storage and are therefore affordable to those in urgent need. Perhaps the Minister will also comment on that.
Sixthly, researchers are undertaking critical work to improve the use and monitoring of insecticide in India to assist visceral leishmaniasis elimination programmes. VL is a fatal disease if untreated, as we have heard, but effective control of the sand-fly is vital to reduce transmission to some of the poorest people of India, Nepal, Bangladesh and elsewhere.
Seventhly, LSTM researchers are involved in reducing the burden of sleeping sickness in several countries, with cases now at the lowest reported level ever—fewer than 3,000 per year. Perhaps the Minister can tell us how and when we expect to see this reach zero.
To conclude, around 1 billion neglected tropical diseases are treated each year via donated quality drugs to the poorest people most in need at lowest per capita cost of any health intervention. This is often called, “the best buy in public health”, addressing equity, human rights, disability alleviation, and based on effective partnerships and alliances from community to global level. It is crucial work and my noble friend is right to press the Government to build on the progress made since the 2012 London declaration.
The Lord Bishop of Peterborough
My Lords, I am grateful to the noble Baroness, Lady Hayman, for raising this short debate. I rise to highlight the issue of leprosy, and I am also grateful to the noble Baroness, Lady Northover, for mentioning that briefly in her contribution.
I also express surprise that the Government seem to be less committed to supporting research into leprosy or the eradication of this terrible scourge than they might be. I suspect that many people think of leprosy purely as a disease of Bible times, but, according to the World Health Organization’s 2016 figures, more than 200,000 people are diagnosed with leprosy every year—10% of them children. There is an effective cure, but many people go untreated, and around 3 million people live with leprosy-related disability.
Leprosy is endemic in 14 countries today, in South Asia, Africa, the Pacific and South America. The complications when it is untreated include severe disfigurement and blindness. But discrimination against leprosy sufferers—some of it by statute in places where leprosy is grounds for divorce, confinement or confiscation of property—makes it a major social problem and a factor in mental illness. Leprosy was listed in the London declaration of 2012 and targeted for eradication by 2020. The Government have made some limited investment in the social aspects of the disease, but none that I can find in the scientific research necessary for eradication. I urge the Minister to include leprosy in the funding priorities for the NTD programme.
There are, of course, other bodies committed to working in this area—I support and commend the work of the Leprosy Mission, for example—but, without government funding, the targets for 2020 are most unlikely to be met.
Viscount Simon (Lab)
My Lords, I congratulate the noble Baroness, Lady Hayman, on getting this debate before us after a number of tries. I have a particular interest in this debate as, in east Africa in 1958, I contracted a nasty form of malaria, which left me for about 10 days totally unaware of what was happening and with the officer cadet on duty having to observe my state of health every 15 minutes.
Neglected tropical diseases comprise a diverse group of 17 communicable diseases which prevail in certain conditions in 149 countries and affect more than 1.3 billion people, most of whom are living in poverty, without sanitation and in contact with infected animals and livestock, as has already been mentioned by other noble Lords. Evidence recently published indicates that there is a heavy geographical overlap between malaria and the neglected tropical disease known as lymphatic filariasis, or LF. Both diseases are transmitted by the same mosquito species in sub-Saharan Africa. LF, also known as elephantiasis, is treatable and curable, but unfortunately the treatment does not reverse the effects of the parasitic infection, which damages the lymph nodes and causes the swelling of limbs. This can often result in lifelong disability, which again has already been mentioned.
To date, synergy between malaria and LF control programmes has been mostly in the form of accidental side-effects of malaria control. There are worries about insecticide resistance, showing the need for an efficient, sustainable and well thought-out approach to controlling multiple diseases. The benefits from attacking two diseases with the same interventions should be exploited to a greater extent in elimination programmes. Like others, I would be interested to learn what measures DfID will take to ensure integration between malaria and NTD control programmes that use similar interventions. This needs clarification.
Baroness Masham of Ilton (CB)
My Lords, I thank my noble friend Lady Hayman for all she does on this subject. One aim of the declaration is to enhance collaboration and co-ordination on neglected tropical diseases at national and international levels, through public and private multilateral organisations, in order to work more efficiently and effectively together. If so many countries were not ravaged by wars, which produces so many refugees and poverty, there might not be so many health problems.
In 2015 alone, pharmaceutical companies donated an estimated 2.4 billion tablets—enough for 1.5 billion treatments—to prevent and treat NTDs. There is now a global problem with the growing resistance to antibiotics, especially in poor countries, which need more education. I had a very good friend, a Holy Rosary nun, who was a health visitor; she worked in Ethiopia and the Cameroons and told me that it is no good bringing babies into this world if they are to die from disease from contaminated water. She became an expert in sinking wells and providing sanitation.
It is encouraging to hear that South Sudan is soon to be certified free of Guinea worm disease, which thrives in poor areas where there is little sanitation and people bathe in and drink stagnant water. I have visited a leprosy colony on one of the islands, and two babies died in half an hour from malaria when I visited a ward in Mombasa where a friend worked. These people working with NTDs are the unsung heroes. There is much to do, and they need concerted support from Governments and anyone involved.
A neglected disease that is a global danger is tuberculosis, which has not had new drugs for a long time. In 2013-15, there were an estimated 480,000 new cases of multidrug resistant TB in the world. There are substantial differences in the frequency of MDR-TB among countries. In some cases, more severe drug resistance can develop; extensively drug-resistant TB is a more serious form of MDR-TB, caused by bacteria that do not respond to the most effective second line anti-TB drugs, often leaving patients without any further treatment options. Worldwide, only 52% of MDR-TB patients and 28% of XDR-TB patients are successfully treated. Infections that are resistant are much more expensive and take much longer to treat. It is vital that global leadership be provided on matters critical to TB. Ending the TB epidemic by 2030 is among the health targets of the newly adopted sustainable development goals but, unless there is less poverty in the world, that will be difficult to achieve. Also, resistance to a form of HIV treatment, antiretroviral therapy, is increasing around the world. The co-infection of HIV and TB, which are resistant to treatment, is very serious. So many people have been working on vaccines. Like my noble friend Lord Rea, I ask the Minister what hope there is of vaccines for TB, HIV and other diseases.
Baroness Warwick of Undercliffe (Lab)
My Lords, I am grateful to the noble Baroness, Lady Hayman, for her tenacity in keeping this issue high on the agenda and for giving the House this opportunity to consider the progress being made in combating neglected tropical diseases. It is certainly worth celebrating. In January, the WHO published an impressive catalogue of progress made in the prevention, control and elimination of NTDs such as Guinea worm disease, sleeping sickness, river blindness and trachoma. The collaboration between the WHO and the global NTD community has clearly had a tremendous impact, but the task remains enormous and we have only four years to meet the WHO’s road map targets. Although we are reaching more people than ever, we need to accelerate to stay on track. Last year’s progress report on the London declaration points out that the road map’s drug donation programme alone is not enough. The coverage and reach of programmes must increase for all these diseases.
I have two questions for the Minister. First, the UK Coalition against Neglected Tropical Diseases said that there must be national government leadership to integrate programmes with other health, water, sanitation and education initiatives. DfID has promised to help countries build “resilient, responsive health systems”. What priority are the Government giving to supporting health systems in the countries dealing with NTDs? What practical steps are we taking in the UK to ensure that donated treatments, surgical interventions and hygiene promotions are delivered to where they are so desperately needed?
My second point is about research. Even as some NTDs are eliminated, others will take their place. Mycetoma joined the list of poverty-related diseases last year. It is just one of the many tropical, poverty-related diseases affecting the same populations and sharing many features with NTDs. Advancing research and development is essential in tackling the next bend in the road map. Priorities must be debated, but the need for more research and funding remains constant. Globally, in recent years, 60% of clinical research on poverty-related diseases, including NTDs, has been conducted in collaboration with European member countries of the European and Developing Countries Clinical Trials Partnership. Historically, the UK and France have been part of these collaborations, due to our former colonial ties. Several other European countries are now increasing their research interests in PRDs and collaborating both with each other and sub-Saharan African countries. Programmes such as EDCTP, promoting cross-national research, make this possible.
To make progress against these hideous diseases and future threats to global health, existing and new scientific partnerships must be able to flourish. It is so important that the UK collaborates with our European counterparts. Among the many uncertainties that lie ahead for UK involvement in European research programmes, has this area been highlighted in the Prime Minister’s agenda for Brexit discussions? Can the Minister reassure us that the UK’s research expertise and commitment to the London declaration goals will continue to play their part as we reach 2020?
Baroness Sheehan (LD)
My Lords, I add my thanks to those of other noble Lords to the noble Baroness, Lady Hayman, for finally securing this debate. It comes at an opportune moment for me as just last week I visited the headquarters of global health institutions working in the fight against malaria, HIV/AIDS and TB. While none of those is, technically, neglected tropical diseases, there are nevertheless many lessons that we can learn from the global fight against these big three killer diseases. I will pick out just three from among the many challenges.
The first is communicating key messages to affected communities, a point made by the right reverend Prelate the Bishop of St Albans. The other two points were picked up by other noble Lords. The second issue concerns the in-country training of medical practitioners to administer drugs effectively. The noble Baronesses, Lady Chalker and Lady Barker, spoke forcefully on that. Thirdly, we need to recognise that prevention and long-term sustainable control are key to success in tackling NTDs. My noble friend Lady Northover made the point that no resurgence is a key goal if we are to be successful.
I focus on TB as an example. That disease was the scourge of Victorian times in the UK. However, with improved public health, less overcrowding and better nutrition we were able to control it effectively—crucially, without the use of drugs, although, of course, antibiotics helped with the final push. That is the key message I want to get across.
Prevention has to be the first line of defence. Effective prevention needs an integrated holistic approach, starting with disease surveillance to identify hotspots, to enable an effective targeted response. In hotspots, to be effective, the mass administration of drugs must be followed by WASH initiatives—again, the noble Baroness, Lady Chalker, spoke about this—that is, water, sanitation and hygiene initiatives, coupled with vector control and education about local factors that perpetuate the disease. Overarching all this is the need to tackle gender and child inequalities, ensuring that women and children are not left behind, because all too often they are left untreated. They are inadvertently most active in infecting others—women through their role as primary carers and children as they play together.
Why have these diseases been neglected and why are they called neglected tropical diseases? The reason lies in the fact that in general they tend not to be direct killers but instead leave people with disfiguring disabilities, which impact on their schooling, work and economic independence. In 2010, the Global Burden of Disease Study, the precursor to the 2012 London declaration, confirmed that collectively they rank as the most common affliction of the world’s poor, blighting the lives and livelihoods of more than a billion people. If developing countries are to pull themselves out of poverty, these diseases must be eradicated. Eradication, however, will need increased focus on research and development. The Ebola outbreaks in 2014 and the 2015-16 Zika epidemics in the western hemisphere highlighted an almost empty pipeline of new NTD products. I would be very interested to hear the Minister’s response to the Ross fund’s work with respect to NTDs.
The 2012 London declaration will come to an end in 2020. Given that NTDs are an indicator for a number of SDGs, in particular SDGs 1, 3, 6, 10 and 11—I might say what they are later if I have time—what commitment or strategy is planned for post-2020? Could international diplomatic pressure be brought to bear to expand commitment to the London declaration? Lastly, could the Minister and his colleagues in government give some thought to placing NTDs on the G20 agenda given that most NTDs and other poverty-related diseases are also found among the poor in developed countries?
Lord Collins of Highbury (Lab)
My Lords, the first time that I participated in a debate on this subject was on 30 January 2013. Like today, that first anniversary debate of the London declaration was initiated by the noble Baroness, Lady Hayman. I, too, thank her for once again ensuring that this vitally important subject is brought to public attention.
NTDs remain the most common infections among the world’s poorest communities and affect, as we have heard, close to one in six of the global population. As the WHO NTD head put it,
“the combination of the NTD Roadmap and the London Declaration has been a game-changer”.
However, he reminded us:
“The next four years will be crucial in achieving the 2020 targets as we continue to work to integrate interventions into the broader health system and development agenda so that no one is left behind”.
As the Minister pointed out, while NTDs are not always fatal, their effect on individuals and communities can be devastating. The brunt is often felt by women and children, which acts as a serious impediment to economic development in many countries. On that point, what progress has the department made in measuring the impact of its NTD funding on women and girls, who disproportionally suffer from NTDs and the stigma attached to them?
As the noble Baroness, Lady Masham, pointed out, nor must we forget that individuals with NTDs are at higher risk of contracting, or not recovering from, HIV/AIDS, malaria and TB, because they weaken the immune system. On that point, I welcome the UK replenishment of the Global Fund, but can the Minister tell us what assessment has been made of the value of strengthening AIDS, TB and malaria investments, with the collaboration of national NTD programmes?
Reference has been made in the debate to the recognition given in the SDGs. Goal 3—healthy lives—has given the fight against NTDs new momentum, which is a positive thing. The noble Baroness, Lady Northover, referred to the £1 billion Ross fund and the Gates Foundation, from which £200 million has been specifically allocated to NTDs. Like the noble Baroness, I would like to understand what progress has been made since that announcement in distributing work such as funding new research areas, vaccines and drugs.
One of the things every noble Lord mentioned is that the EU is one of the top global funders of NTD research, and the UK has an exceptionally strong track record in leading joint European research initiatives. Will the Minister say what assessment DfID has made of the impact of losing access to this vital source of research income following Brexit?
To meet the 2020 targets, 75% coverage would have had to be reached by the end of 2015. Although data for 2015 are not yet fully available, the target is unlikely to have been met. What does the Minister identify as the key barriers to progress and finding solutions?
At the beginning of the debate the noble Baroness mentioned the forthcoming WHO NTD summit. I declare an interest here; I am a member of the APPG on NTDs, and I signed a letter specifically to the Secretary of State asking her to attend the summit, not only to demonstrate the UK’s role in the fight against NTDs but to use the opportunity to encourage others to meet our level of commitment.
The Minister of State, Department for International Development (Lord Bates) (Con)
My Lords, this has been an excellent debate, with 14 contributions. At the last minute, those were allowed to increase from two to five minutes; I am reliably informed by the Whips that my contribution cannot increase in the same proportion, and therefore I am limited to 12 minutes. There are a number of important issues to cover, but if I can, I will go through this at some pace.
Like the noble Lord, Lord Collins, I can trace the antecedents of raising these issues back a number of years—not quite back to 2013, but to 6 February 2014, when I responded from the Front Bench to the debate in the name of the noble Baroness, Lady Hayman, on this issue. The noble Lord, Rea, is right to say that the noble Baroness, Lady Hayman, deserves a great tribute for ensuring that neglected tropical diseases are not neglected in your Lordships’ House. We thank her for that and commend the work of the very active APPG on Malaria and NTDs, of which she is vice-chair.
NTDs affect 1.6 billion of the world’s poorest people, as the noble Baronesses, Lady Hayman and Lady Northover, reminded us, and they result in disability and have a tremendous impact on people. They cause a great economic burden for people, as the noble Baroness, Lady Sheehan, reminded us, as well as creating stigma and hardship, which were also mentioned.
Reference was made by the noble Baronesses, Lady Hayman and Lady Warwick, and the right reverend Prelate the Bishop of St Albans to the progress that has been made. The number of people at risk from NTDs fell from 2 billion in 2010 to 1.6 billion in 2015. In the 1950s, before programmes started, one in four people over the age of 40 went blind from river blindness in some of the highest endemic areas. Blindness caused in this way has now been virtually eradicated.
The noble Baroness, Lady Northover, who served as a Minister in the department during the coalition Government, reminded us of the visit to the House of Lords by President Carter, who spoke in the Robing Room—an event that I, too, attended. He spoke about Guinea worm eradication. Only three countries reported a total of 25 cases of guinea worm disease in 2016—down from 3 million cases a year when the programme started in 1986. This is well on the way towards the target that has been set and shows what can be achieved in this area.
A number of noble Lords referred to the high-profile London declaration event in 2012, when the UK committed an additional £195 million to tackle these diseases. The UK, along with the US, is a world leader on NTDs. We are meeting our commitments. The UK supports high-performing programmes tackling a range of NTDs, and these programmes are delivering results. DfID programmes delivered more than 136 million treatments for NTDs in 2016. We have supported over 60,000 surgeries to prevent blindness due to trachoma, and over half a million people have been screened for kala-azar, a disease that is invariably fatal if not treated.
Much of our support for the implementation of NTD programmes is through our world-class British institutions. The noble Lords, Lord Stone and Lord Alton, referred to many of these, particularly the Liverpool School of Tropical Medicine, and I pay tribute to the expertise that is to be found there. I am delighted to accept the invitation from the noble Lord, Lord Stone, to meet the SCI group at Imperial and would be very interested to find out more about its work.
Many noble Lords, including the noble Baronesses, Lady Warwick and Lady Barker, referred to the importance of research. This is at the heart of what we do. DfID is committed to spending approximately 3% of its annual budget on research, and of course that also impacts on the NTD process. We also support research into new drugs, diagnostics and better vector control, as well as operational research into the best ways to implement programmes. I very much recognise the point made on vectors by the noble Baroness, Lady Barker, as I do the very important point about prevention made by the noble Baroness, Lady Sheehan. The UK Government have a strong track record of supporting successful product development research through public-private product development partnerships, such as the Drugs for Neglected Diseases initiative and the Foundation for Innovative New Diagnostics.
Tackling NTDs is highly cost effective, as the noble Lord, Lord Stone, reminded us. The average cost of treating one person for a range of commonly occurring NTDs is about 50 US cents. The noble Lord, Lord Alton, described it as a “best buy”, which it very much is. NTDs are an excellent example of a unique public-private partnership: most of the medicines are donated by pharmaceutical companies, which have pledged drugs valued at $17 billion between 2014 and 2020—a point made by the noble Baroness, Lady Masham. Without this very generous support there would be far less progress and considerably higher costs.
A number of noble Lords referred to the London declaration. I am pleased to report that there will be a very high level of representation at the event taking place on 19 April. I do not in any way want to undermine the importance of NTDs, but when we discussed this as a ministerial team, we realised that so many important meetings are taking place this very month: this week on Syria, and in a couple of weeks’ time on Yemen and the wider humanitarian crisis in Africa. However, I will certainly convey to the department and the Secretary of State the importance that your Lordships attach to this initiative and the gathering that will occur on 19 April.
The noble Baroness, Lady Barker, referred to the interconnectivity of scientific research with the attempts we are making. That is a point I recall being made by David Nabarro, who is a very strong candidate to be the next director-general of the World Health Organization.
The noble Lord, Lord Rea, the noble Baroness, Lady Sheehan, and my noble friend Lady Chalker raised the importance of WASH. This very much links to what the noble Baroness, Lady Sheehan, said about prevention. WASH is the best form of prevention that we know for NTDs. There is strong cross-sectoral working on this, in particular on increasing access to water and sanitation. My noble friend asked what commitment we have made in this area. We have a very strong manifesto commitment to increase clean water access to 60 million people during the lifetime of this Parliament, which is sustainable development goal 6. That is a major programme which we are working on.
My noble friend also raised the importance of engineers. I am delighted that through the Commonwealth Scholarship Commission we are giving access to many students from sub-Saharan Africa to come and study at our world-class universities and take that expertise back with them.
The noble Viscount, Lord Simon, raised the importance of co-infections. He particularly focused on malaria. The noble Baroness, Lady Masham, referred to TB, and the noble Lord, Lord Collins, referred to collaboration on HIV-TB. We fully understand and stress that these are all very important areas.
A key element is the availability of good quality data and the disaggregation of those data in connection with the SDGs. We want to ensure that programmes collect and analyse data on how we are making progress against targets and disaggregate those data to ensure that we are reaching girls, women and other vulnerable groups—an issue that the noble Lord, Lord Collins, asked us to work on.
The right reverend Prelate the Bishop of St Albans raised the strong partnerships that we have with faith groups. Through our faith partnerships we work very closely with those groups in a number of parts of the world. He talked about Sierra Leone and, in the past week, I have been looking at what the Anglican community is doing in the terrible situation in South Sudan, where the conflict is making the treatment of neglected tropical diseases and the effects of famine incredibly difficult. That is a real manmade tragedy.
We are making efforts to work with other donors, in particular USAID. I take the important points that were made about the USA, with which we are working very closely. The draft budget was prepared by the President and will be turned into a formal budget to be announced in May. It then, of course, has to work its way through Congress. We are looking very closely at his nominee for USAID. The United States, through its private foundations and as a Government, has played a critical role in this and I very much hope we will be able to work with it in the future in delivering this absolute best-buy for development investment.
Our efforts to map the NTDs have helped to determine the geographical distribution of diseases, a point made by the noble Lord, Lord Alton, so that we can target resources where they are most needed. We are now expanding access to treatment. As countries are now able to stop mass drug administration for some diseases, it will be critical to carry out the surveillance necessary to ascertain progress and to ensure that low infection levels are sustained. However, we must not forget that while some countries are reaching that stage, others are only just starting in their efforts to tackle NTDs.
On this point I echo the urging of the noble Baroness, Lady Hayman, in introducing the debate, that there is no question of us regarding this as “steady as she goes” or, in the phrase of the noble Baroness, Lady Barker, taking our foot off the pedal. This is absolutely essential to the sustainable development goals. It is a treatment programme that works and we want it to continue.
The noble Lord, Lord Rea, the right reverend Prelate the Bishop of Peterborough, and the noble Baronesses, Lady Northover and Lady Masham, asked what progress was being made on leprosy. According to the World Health Organization, there were over 210,000 new cases of leprosy reported in 2015. We need to increase progress. In 2016, the World Health Organization launched a global leprosy strategy for 2016-20 and UK aid match is supporting work to improve the lives of people affected by leprosy and other NTDs in Mozambique and other countries.
At the conclusion of my remarks I come back to that very important summit. While the UK across a number of levels—from our great research base to the work that many people have been doing through medical science in this area—is advancing the cause and has made great progress, it is vitally important that we use the occasion and the platform of the World Health Organization joint summit on NTDs on 19 April to ensure that other donors come forward and meet their responsibilities towards eradicating these diseases and meeting the sustainable development goals in these areas.
As to the consequential nature of the SDGs, I have been ticking them off and I think we have covered all 17 of the goals, from partnerships, to conflict in number 16, to eradicating poverty in number 1, to education in number 4, to gender equality in number 5. It is a real point of endorsement as to how the SDGs are rightly a lens through which we judge our progress on this.
I again thank all noble Lords who have contributed to the debate. I shall reflect further on it and feed the messages back to my colleagues at the department as we move forward.