Neglected Tropical Diseases: A looming danger

N S Abhilasha

Introduction
As the novel coronavirus captures the spotlight of global health politics, diseases clubbed as the Neglected Tropical Diseases (NTDs) have been forgotten. It is likely that already overburdened public health systems will have to deal with many more difficult diseases along with the current pandemic. Diseases like leprosy, hookworm infection, leishmaniasis, yaws and trachoma affect over a billion people living in the poorest parts of the world. These diseases require regular monitoring; but with COVID-19 at hand, the public-health system needs to think on its feet.

Ways to deal with NTDs amidst the chaos of COVID-19 are apparent if we probe into political economy around NTDs,. In the current strategy of World Health Organization (WHO) to deal with NTDs, pharmaceutical companies play a dominant role. Much less recognized, is the efforts of development practitioners working at the lowest levels of organizational bureaucracy. To understand this unequal relation let us take the example of two diseases, leishmaniasis (protozoan infection spread by sandflies) and soil-transmitted helminthiasis (infections caused by parasitic worms).

History, Economics and (Anti) Politics of NTDs
The term ‘tropical disease’ has been in use since the seventeenth century to denote diseases that the European colonists encountered in warmer climates. The term however is a misnomer as many tropical diseases like dengue and malaria were equally prevalent in temperate regions. As several developing countries have failed to secure for all its people safe housing, sanitation and nutrition, NTDs continue to affect them. By the twenty first century, it was clear that a concerted plan was necessary to deal with these tormenting diseases.

Clear goals and targeted actions were laid down in the United Nations Millennium Development Goals (MDGs) in 2000. Grabbing the opportunity, pharmaceutical companies intensely lobbied the WHO to make neglected diseases a part of MDGs. Poor countries were seen as potentially untapped markets for selling laboratory based drugs and testing kits. Early diagnosis and treatment along with mass distribution of drugs became the mantra for the WHO to deal with NTDs. We see here a reflection of James Ferguson’s concept of ‘anti-politics’ where experts push for techno-scientific solutions to resolve deeper political and structural problems of developing countries.

To say that development goals are shaped by experts is to describe only a part of the picture. Stuart Corbridge et al in Seeing the State (2005) says that development processes are shaped equally by development practitioners or workers working at lower levels of organizations. Alan Fenwick, the founder of Schistosomiasis Control Initiative (SCI) says that it is the social and political networks created by community health workers, volunteers and the local administration that produce encouraging results in the prevention of neglected diseases. We cannot think of preventing NTDs if we do not consider the problems of these development practitioners.

Leishmaniasis
The diseases caused by various species of protozoan parasite Leishmania, present various clinical symptoms- cutaneous, mucocutaneous and visceral. These diseases are spread through the bite of sandflies, a vector similar to mosquitoes. Cutaneous and mucocutaneous forms of leishmaniasis lead to lesions on the skin, the latter leading to disfigurement of the face. People affected with these often remain hidden to avoid social stigma. While these are common infections, neither is fatal. Visceral leishmaniasis, an endemic disease in parts of India, Bangladesh and Nepal is a fatal one.

The current strategy used for leishmaniasis is early detection of cases and early treatment. Assuming that hospitals will not attend to medical needs other than COVID-19, people would be unwilling to visit them to get tested for leishmaniasis. Further, lockdown within the countries has reduced the travel of healthcare workers and volunteers to remote places to carry out testing. With the entire public health system focused solely on COVID-19, early detection appears a far call this year. Amidst the current pandemic, vector control activities have also been ignored.

Early treatment depends upon availability of drugs. More complicated host-pathogen interaction, more tedious is the process of drug discovery and development (DDD). Anti-leishmanial drugs have to penetrate the immune cells of human body to reach the parasite, without destroying the cell itself. At times, serious cases of leishmaniasis require anti-cancer drugs which are very expensive. As COVID-19 has disrupted transport and communication channels, pharmaceutical companies will cover their costs by charging a higher price for such drugs.

Soil-transmitted Helminthiasis
More than two billion people world-over get infected by parasitic worms or helminths. Soil-based worms like hookworms, roundworms and whipworms are called soil transmitted helminths (STH). Poor sanitation facilities, infected vessels, unhygienic cooking areas, absence of hand-washing habits are some of the most common reasons leading to helminth-based diseases. Long term cognitive and physical impairment is reported among children affected by STH infection. Hookworm infection is one of the most widespread STH infection in Bangladesh, Sri Lanka, Afghanistan, Pakistan, Nepal and India.

Helminths or parasitic worms are tackled through regular deworming in schools with anti-helminth drugs. In India, Anganwadi workers and teachers carry out deworming of children between the age 1-14 years. These drugs are usually mebendazole, albendazole, or pyrantel pamoate. Even a single dose of albendazole has a 72 percent cure rate. With no schools during the lockdown, it will be an uphill task for school authorities and the local government to ensure distribution of drugs. In any case, mass drug administration, without any attention to sanitation or diet, is of little use to prevent reinfection. Hookworm cases are being increasingly reported in the rural areas of the US, affecting African-Americans more than whites. It takes little effort to imagine the possible scenario in developing countries like India.

Conclusion
2020 was set by the WHO as the target year for controlling and eliminating several Neglected Tropical Diseases. The current strategies of the WHO; active disease management and preventive chemotherapy celebrate the work of pharmaceutical companies. Governments likewise offer doles like tax rebates to pharmaceutical companies, security to investors and controlling competition from generic drug manufacturers. However, it is the development practitioners (health workers, volunteers, nurses and teachers) who give flesh to development agendas of international organizations. Only with monetary bonuses and health coverage can foot soldiers continue their fight against NTDs without fearing about their families’ health. Social insurance is also necessary for factory workers in pharmaceutical companies, who are putting their lives in danger to produce ‘essential commodities’. If top players of global health do not wake up, the problems posed by NTDs will only compound the present crisis.

References
Ferguson, James (1994). Anti-Politics Machine: ‘Development’, Depoliticization and Bureaucratic Power in Lesotho. London: University of Minnesota Press.
Ian Harper & Melissa Parker (2014).The Politics and Anti-Politics of Infectious Disease Control, Medical Anthropology, 33:3, 198-205.
Stuart Corbridge et al (2005). Seeing the State: Governance and Governmentality in India. New York: Cambridge University Press.
WHO (2010). Working to overcome the Global Impact of Neglected Tropical Diseases. First WHO Report on Neglected Tropical Diseases.

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Jun 2, 2020