Neglected Tropical Diseases

Lord Trees Excerpts

Wednesday 11th July 2018 Lords Chamber

Asked by

[Lord Trees]

To ask Her Majesty’s Government what assessment they have made of progress made in combating neglected tropical diseases following publication of the Fifth Progress Report on the London Declaration on Neglected Tropical Diseases.

[Lord Trees (CB)]

My Lords, given that there is another major attraction this evening, I am very grateful to noble Lords who have put down their names to speak in this debate.

The neglected tropical diseases are a group of 20 bacterial, viral, fungal and parasitic diseases—to which snake-bite has recently been added—which affect more than a billion people a year in some of the poorest countries of the world. Recognition of their importance as a burden on health in those countries was enhanced by bringing them together under the term “neglected tropical diseases”, which we shall call NTDs, and was further strengthened by the London declaration of 2012. I shall try to limit my use of lots of names, for I fear Hansard might get apoplexy dealing with visceral leishmaniasis, schistosomiasis, onchocerciasis and the like. Suffice it to say that the colloquial names of those diseases vividly convey their consequences, such as elephantiasis, river blindness, or the appalling biblical disease of leprosy, which is still prevalent in many poor countries.

A key feature of the NTDs is high morbidity, with chronic disability, disfigurement, social stigma and long-term loss of health affecting the poorest members of society. NTDs are a result of poverty, but in a malignant circle they are a cause of poverty, because they reduce the potential of millions of people to improve their economic well-being.

While chronic disease is a feature, some NTDs cause considerable mortality. For example, snake-bite is estimated to kill about 100,000 people a year. We are also beginning to understand the important role that NTDs play in predisposing to a range of other significant health problems, such as mental ill health, HIV/AIDS, epilepsy and cancer, among others. While the impact of NTDs is huge, in many cases we have the tools available to tackle them so that, given the will and the funding, we can do a great deal about their impact now.

The London declaration of 2012 focused specifically on 10 NTDs for which there are drugs available and which could be tackled by mass drug administration, which I shall refer to as MDA. That has been facilitated by donation of key drugs by several pharmaceutical companies, and the scale and significance of this is massive. Arguably, this is the greatest philanthropic gesture by industry to benefit the global public good there has ever been. Some $2 billion to $3 billion-worth of drugs is donated annually and in 2016 more than a billion treatments were donated in 130 countries.

Another important development has been the linking of NTDs to the achievement of the sustainable development goals. MDA is a great example of universal health coverage and tackling NTDs will contribute greatly to the achievement of the SDGs, especially SDG 3 to ensure healthy lives and promote well-being for all at all ages. Conversely, the attainment of other SDGs, such as the water and sanitation objectives of SDG 6, will contribute hugely to NTD control.

The progress to date in controlling NTDs has been remarkable. Between 2011 and 2016 the coverage of MDA has nearly doubled from 37% to 63% of the target populations and concomitantly the global population at risk has fallen by nearly 500 million people. In 10 countries lymphatic filariasis has been eliminated as a public health problem, as has trachoma in five countries; onchocerciasis has been almost eliminated from the Americas; and Guinea worm has been almost completely eradicated from the globe. Major progress has been made in reducing morbidity with other NTDs, all of these in countries with logistic and economic handicaps.

The UK’s contribution has been huge and is something of which we should be proud. Funding from the UK Government has been pivotal, both for research and for disease control. I am sure that the Minister will tell us about this, so I will not steal his thunder. UK scientists, too, have been and continue to be at the forefront in tackling these diseases. Here I pay particular tribute to my former colleague Professor David Molyneux, who has been at the Liverpool School of Tropical Medicine for many years and has been a tireless campaigner on NTDs. This Parliament’s All-Party Group on Malaria and NTDs, under the committed chairmanship of Jeremy Lefroy MP, has been extremely active and influential.

In tackling these diseases, a “one health” approach is extremely important, where as well as medical scientists, veterinary scientists can make an important input. This may be where infections are known to be zoonotic—that is, transmissible between humans and animals—or in other cases where we are discovering a role for animal hosts not hitherto known, such as in the epidemiology of schistosomiasis and of Guinea worm. Most significantly, it can be in the development of drugs where the commercial market to treat worms in animals has driven research and discovery of key drugs now being repurposed and donated for MDA programmes in humans, such as ivermectin for onchocerciasis.

That brings me to rabies, a truly horrific zoonotic NTD estimated to kill nearly 60,000 people a year, of whom more than 40% are children. That is year in and year out and compares to the 11,000 that died in the recent tragic Ebola outbreak in west Africa. Once clinical signs of rabies appear, whatever the treatment given, 99.9% of all patients die a horrible death, yet this is preventable. We have the technical tools required to consign this disease to history. Almost all cases of human rabies are caused by the bite of an infected dog, but we have a simple, safe and effective vaccine to immunise dogs. Field research in a number of regions and countries in Africa, the Americas and Asia has demonstrated the success of canine vaccination campaigns in eliminating human rabies. An international effort is now under way with the key organisations: the WHO, the OIE—the world organisation for animal health—the FAO and the Global Alliance for Rabies Control, which has very recently produced a global strategic plan to end dog-mediated rabies by 2030, the Zero by 30 campaign. Key to that campaign is a dog vaccine bank that the WHO has already set up. I ask the Minister: what specific support is DfID giving to rabies control? This is a disease on which the UK could single-handedly make a huge, cost-effective impact.

Because the dog vaccine is largely an altruistic vaccine, in that it is given to dogs in order to benefit public health, it is difficult for human health ministries in low-income countries to justify expenditure on a dog vaccine from their budgets. On the other hand, impoverished dog owners are unlikely to vaccinate their dogs to benefit the general public. The donation of dog vaccines to the WHO’s vaccine bank would cut this Gordian knot and catalyse progress. Professor Sarah Cleaveland of Glasgow University, one of the world’s leading authorities on rabies control, has estimated that only $15 million to $20 million per year would purchase enough dog vaccines for all of Africa. I suggest to the Minister that a commitment to provide dog vaccines on such a scale would be a huge boost to the Zero by 30 campaign and would leverage a colossal amount of support in delivering those vaccines by NGOs, charities and ministries of health in low-income countries, acting under the umbrella of the global strategic plan to end almost all human deaths from rabies in the world.

In conclusion, the progress made in reducing the effect of all NTDs has been a remarkable testament to the efforts of the international community. To cement the progress made to date and drive these diseases to oblivion, it is essential that we maintain our efforts. Endemic countries need to take more responsibility. While the healthcare budgets of low-income and middle-income countries may be modest, the cost of delivery of donated drugs—about 20 cents to 30 cents per person per year—would amount to only 1% to 2% of such budgets, yet donated drugs are not getting delivered. We need also to better integrate interventions between various NTDs and with other healthcare interventions to be more cost-effective.

In the affluent world, we need to maintain our commitment. There is a funding gap. The WHO has estimated that an additional $300 million to $400 million is required per year up to 2020. Currently, of world Governments, the UK and the US have been the principal donors; other affluent nations need to increase their efforts. The UK pledge to spend 0.7% of GDP on overseas aid is an admirable example. We need to recognise that, even when there are many calls on public expenditure, improving the health and welfare of those in poorer countries is not only ethically admirable but makes sound sense.

Let me elaborate. Analysis has shown that, given the scale of drug donation, NTD interventions are one of the most cost-effective measures in public health, one estimate giving a 25:1 rate of return. In addition to being highly cost-effective, support for NTD control is quite simply enlightened self-interest. I need hardly emphasise to your Lordships that the issue of economic migration is a huge challenge to the affluent northern countries. I submit that the solution lies not in fences and walls but rather in improving the health, and hence wealth, of populations ravished by endemic disease, so that people can stay at home assured of a healthy, productive and economically adequate life.