Waging peace through neglected tropical disease control: a US foreign policy for the bottom billion

Does the medical insurance system really achieved the effect of poverty alleviation for the middle-aged and elderly people in China? Characteristics of vulnerable groups and failure links

BACKGROUND

We examined the physiological, household, and spatial agglomeration characteristics of the health poverty population in China. We identified weak links that affect the implementation of the medical insurance and further improve its effectiveness for health poverty alleviation.

METHODS

A national representative sample from the China Health and Retirement Longitudinal Study (CHARLS) was analyzed. The WHO recommended method was adopted to calculate catastrophic health expenditure (CHE) and impoverishment by medical expenses (IME). We created a binary indicator for IME as the outcome variable and applied the treatment-effect model to analyze the determinants of IME.

RESULTS

The incidence of IME was 7.2% of the overall population, compared to 20.3% of the sample households trapped in CHE. The incidence of IME enrolled in insurance schemes was 7.4% higher than that of uninsured families (4.8%). Economic level, living area, family size, age of household head, having hospitalized members, and participating in insurance were statistically significant for the occurrence of IME.

CONCLUSIONS

The original poverty-promoting policies has not reached the maximum point of convergence with China's current demand for health. The overlapped health vulnerabilities exacerbated the risk of poverty among the elderly and households with high health needs and utilization. In addition, the medical insurance schemes have proven to be insufficient for protection against economic burden of poor households. So, special health needs, age, and household capacity to pay should be comprehensively considered while strengthening the connection between the disease insurance scheme with supplementary insurance.

RUMOURS, RIOTS AND THE REJECTION OF MASS DRUG ADMINISTRATION FOR THE TREATMENT OF SCHISTOSOMIASIS IN MOROGORO, TANZANIA

In 2008 in Morogoro region, Tanzania, mass drug administration (MDA) to school-aged children to treat two neglected tropical diseases (NTDs) - urinary schistosomiasis and soil-transmitted helminths - was suspended by the Ministry of Health and Social Welfare after riots broke out in schools where drugs were being administered. This article discusses why this biomedical intervention was so vehemently rejected, including an eyewitness account. As the protest spread to the village where I was conducting fieldwork, villagers accused me of bringing medicine into the village with which to 'poison' the children and it was necessary for me to leave immediately under the protection of the Tanzanian police. The article examines the considerable differences between biomedical and local understandings of one of these diseases, urinary schistosomiasis. Such a disjuncture was fuelled further by the apparent rapidity of rolling out MDA and subsequent failures in communication between programme staff and local people. Rumours of child fatalities as well as children's fainting episodes and illnesses following treatment brought about considerable conjecture both locally and nationally that the drugs had been either faulty, counterfeit, hitherto untested on humans or part of a covert sterilization campaign. The compelling arguments by advocates of MDA for the treatment of NTDs rest on the assumption that people suffering from these diseases will be willing to swallow the medicine. However, as this article documents, this is not always the case. For treatment of NTDs to be successful it is not enough for programmes to focus on economic and biomedical aspects of treatment, rolling out 'one size fits all' programmes in resource-poor settings. It is imperative to develop a biosocial approach: to consider the local social, biological, historical, economic and political contexts in which these programmes are taking place and in which the intended recipients of treatment live their lives. If this is not done, the world's poor will continue to be neglected.

The untapped cell biology of neglected tropical diseases

The World Health Organization lists a constellation of 17 tropical diseases that afflict approximately one in six individuals on the planet and, until recently, few resources have been devoted to the treatment and eradication of those diseases. They are often referred to as the diseases of the “bottom billion,” because they are most prevalent among the poorest individuals in impoverished tropical nations. However, the few studies that have been performed reveal an extraordinary world of molecular and cellular adaptations that facilitate the pathogens’ survival in hosts ranging from insects to humans. A compelling case can be made that even a modest investment toward understanding the basic molecular and cell biology of these neglected pathogens has a high probability of yielding exciting new cellular mechanisms and insights into novel ways of combating these diseases.

Poverty, health and satellite-derived vegetation indices: their inter-spatial relationship in West Africa

BACKGROUND

Previous analyses have shown the individual correlations between poverty, health and satellite-derived vegetation indices such as the normalized difference vegetation index (NDVI). However, generally these analyses did not explore the statistical interconnections between poverty, health outcomes and NDVI.

METHODS

In this research aspatial methods (principal component analysis) and spatial models (variography, factorial kriging and cokriging) were applied to investigate the correlations and spatial relationships between intensity of poverty, health (expressed as child mortality and undernutrition), and NDVI for a large area of West Africa.

RESULTS

This research showed that the intensity of poverty (and hence child mortality and nutrition) varies inversely with NDVI. From the spatial point-of-view, similarities in the spatial variation of intensity of poverty and NDVI were found.

CONCLUSIONS

These results highlight the utility of satellite-based metrics for poverty models including health and ecological components and, in general for large scale analysis, estimation and optimisation of multidimensional poverty metrics. However, it also stresses the need for further studies on the causes of the association between NDVI, health and poverty. Once these relationships are confirmed and better understood, the presence of this ecological component in poverty metrics has the potential to facilitate the analysis of the impacts of climate change on the rural populations afflicted by poverty and child mortality.

The effect of a health communication campaign on compliance with mass drug administration for schistosomiasis control in western Kenya--the SCORE project

Compliance with mass drug administration (MDA) can be affected by rumors and mistrust about the drug. Communication campaigns are an effective way to influence attitudes and health behaviors in diverse public health contexts, but there is very little documentation about experiences using health communications in schistosomiasis control programs. A qualitative study was conducted with community health workers (CHWs) as informants to explore the effect of a health communication campaign on their experiences during subsequent praziquantel MDA for schistosomiasis. Discussions were audio-recorded, transcribed verbatim, translated into English where applicable, and analyzed thematically using ATLAS.ti software. According to the CHWs, exposure to mass media messages improved awareness of the MDA, which in turn, led to better treatment compliance. Our findings suggest that communication campaigns influence health behaviors and create awareness of schistosomiasis control interventions, which may ultimately improve praziquantel MDA.

Neglected tropical disease and emerging infectious disease: an analysis of the history, promise and constraints of two worldviews

Emerging infectious diseases (EIDs) and neglected tropical diseases (NTDs) are medical terms referring to a group of diseases, yet they are simultaneously socio-political constructs (EID and NTD). When viewed as such, public health interest in EID has been criticised as prioritising free market, Global North interests. This paper asks if the recent turn to NTD, which directs attention and resources to 'the bottom billion' of the world's population, addresses the limitations of focusing on EID. Our approach involves comparing the specific socio-political framing, or 'worldview' of NTD, with that of EID. We examine the distinct history, rationales, morals, political and economic tensions and loci of power entailed in each worldview. This analysis suggests that efforts to foreground NTD constitute a site where humanitarian and biomedical industry actors and actions are increasingly blurred. We examine whether the NTD worldview constitutes a break with or a new version of a free market approach to global health, and whether it reworks or solidifies paternalistic Global North-South relations. We consider some of the limits of work on NTD to date, suggesting that although the NTD worldview does not escape the neo-colonial history of global health, it can actualise it under a different form.

Neglected tropical disease control in post-war Sierra Leone using the Onchocerciasis Control Programme as a platform

Strategic investments in the control of neglected tropical diseases (NTD) spearheaded by the US Government, the British Government and other bilateral donors such as foundations and key pharmaceutical partners have enabled the treatment of millions of people for the five targeted debilitating diseases (lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminthiasis and trachoma), paving the way for the potential elimination as public health problems of some of these diseases. Like many other countries, Sierra Leone has a high burden of these major NTDs. Despite the fragile infrastructure of a health system emerging from a devastating 10-year civil war, the country has successfully implemented the National NTD Control Programme, reaching national coverage in 2010. The NTD Control Programme uses the existing Onchocerciasis Control Programme as a platform and involves primary health workers. The programme has provided extensive training opportunities to health workers at national, district and community levels. The country currently has 31 161 trained community volunteers treating a population of five million people. It is shown that the investments in NTD control are not only to control NTDs but also to strengthen health systems, particularly at the primary level, through extensive capacity building of frontline health workers and community-directed distributors.

Safety of a New Chewable Formulation of Mebendazole for Preventive Chemotherapy Interventions to Treat Young Children in Countries with Moderate-to-High Prevalence of Soil Transmitted Helminth Infections

The primary objective was to evaluate the safety and tolerability of the new chewable formulation of mebendazole to treat soil-transmitted helminth (STH) infections in children ≤10 years old with the goal of using this formulation in preventive chemotherapy programs and expand treatment to young children who are unable to swallow solid tablets. In this open-label, single-arm, phase 3 study conducted at Pemba Island, Zanzibar, Tanzania, children aged 2 to 10 years (median age: 4 years) were administered a single dose of the mebendazole 500 mg chewable tablet. Safety was assessed 30 minutes after dose and 3 days later. Of the 390 (98%) children who completed the study, 195 (55%) had ≥1 STH infection and 157 (45%) had no infection at baseline. The most common STH infections were Trichuris trichiura (51%), hookworm (16%), and Ascaris lumbricoides (7%). Treatment-emergent adverse events (TEAEs) were experienced by 11% of children. There was no difference in the percentage of children experiencing TEAEs between the age strata of 2–5 years and 6–10 years. Diarrhea was reported only in children aged 2–5 years. No correlation was observed between the type or percentage of AEs and presence or severity of infection. A single dose of mebendazole 500 mg chewable tablet was safe and well tolerated in children aged 2 to 10 years.

Innovation for the 'bottom 100 million': eliminating neglected tropical diseases in the Americas

An estimated 100 million people in the Latin American and Caribbean (LAC) region live on less than US$2 per day, while another 46 million people in the US live below that nation's poverty line. Almost all of the 'bottom 100 million' people suffer from at least one neglected tropical disease (NTD), including one-half of the poorest people in the region infected with hookworms, 10% with Chagas disease, and up to 1-2% with dengue, schistosomiasis, and/or leishmaniasis. In the US, NTDs such as Chagas disease, cysticercosis, toxocariasis, and trichomoniasis are also common among poor populations. These NTDs trap the poorest people in the region in poverty, because of their impact on maternal and child health, and occupational productivity. Through mass drug administration (MDA), several NTDs are on the verge of elimination in the Americas, including lymphatic filariasis, onchocerciasis, trachoma, and possibly leprosy. In addition, schistosomiasis may soon be eliminated in the Caribbean. However, for other NTDs including hookworm infection, Chagas disease, dengue, schistosomiasis, and leishmaniasis, a new generation of 'anti-poverty vaccines' will be required. Several vaccines for dengue are under development by multinational pharmaceutical companies, whereas others are being pursued through non-profit product development partnerships (PDPs), in collaboration with developing country manufacturers in Brazil and Mexico. The Sabin Vaccine Institute PDP is developing a primarily preventive bivalent recombinant human hookworm vaccine, which is about to enter phase 1 clinical testing in Brazil, as well as a new therapeutic Chagas disease vaccine in collaboration with several Mexican institutions. The Chagas disease vaccine would be administered to seropositive patients to delay or prevent the onset of Chagasic cardiomyopathy (secondary prevention). Together, MDA and the development of new anti-poverty vaccines afford an opportunity to implement effective control and elimination strategies for the major NTDs in the Americas.

First Universities Allied for Essential Medicines (UAEM) Neglected Diseases and Innovation Symposium

Universities Allied for Essential Medicines organized its first Neglected Diseases and Innovation Symposium to address expanding roles of public sector research institutions in innovation in research and development of biomedical technologies for treatment of diseases, particularly neglected tropical diseases. Universities and other public research institutions are increasingly integrated into the pharmaceutical innovation system. Academic entities now routinely undertake robust high-throughput screening and medicinal chemistry research programs to identify lead compounds for small molecule drugs and novel drug targets. Furthermore, product development partnerships are emerging between academic institutions, non-profit entities, and biotechnology and pharmaceutical companies to create diagnostics, therapies, and vaccines for diseases of the poor. With not for profit mission statements, open access publishing standards, open source platforms for data sharing and collaboration, and a shift in focus to more translational research, universities and other public research institutions are well-placed to accelerate development of medical technologies, particularly for neglected tropical diseases.

Emerging and neglected tropical diseases: translational application of proteomics

The challenges of identifying and controlling emerging diseases impact individual health, as well as political, social and economic situations. In this review we discuss the role of proteomics for investigation of pathogen discovery, outbreak investigation, bio-defense, disease control, host-pathogen dynamics and vaccine development of emerging and neglected tropical diseases (NTDs). In the future the discipline of proteomics may help define multiple aspects of emerging and NTDs with respect to personalized medicine and public health.

Turning neglected tropical diseases into forgotten maladies

Because they afflict mostly poor people in poor countries, killing relatively few compared to the many who suffer from severe chronic disabilities, a large cluster of infections deserve the label of neglected tropical diseases (NTDs). That is changing as these diseases' enormous health, educational, and economic toll is better understood, including how they interact with HIV/AIDS, malaria, and other illnesses. Several NTDs could be controlled or even eliminated within a decade, using integrated, highly cost-effective mass drug administration programs together with nondrug interventions. Research is needed to provide additional means of control for these conditions and make elimination feasible for still others.

Multiparasitism a neglected reality on global, regional and local scale

This review focuses on the issue of multiparasitism, with a special emphasis on its characteristics, its extent in eastern Asia and its significance for infectious disease control. Multiparasitism is pervasive among socially and economically disadvantaged or marginalised communities, particularly in tropical and subtropical areas. Intestinal parasites are the most numerous group, but an array of parasites is located elsewhere than in the human gastrointestinal tract. Although multiparasitism has been recognised for decades, in-depth studies are rare, and its public health and economic implications have yet to be fully elucidated. The assessment of multiparasitism is hampered by a lack of sensitive broad-spectrum diagnostic tools and the need to collect multiple biological samples for detailed appraisal. Non-specific symptoms and mainly subtle effects complicate the appreciation of its influence on cognitive and physical development, health, economic productivity and general well-being. Multiparasitism has been reported from virtually every eastern Asian country, and studies regarding the extent of multiparasitism and its effects on child health have been implemented in the region. However, new research is needed, as no comprehensive evaluations of multiparasitism in eastern Asia could be identified. Two case studies pertaining to multiparasitism at the local and regional scale are presented. Multiparasitism was rampant in an ethnic minority village in southern People's Republic of China where the challenges associated with its thorough evaluation are illustrated. The results from a cross-sectional survey covering 35 villages highlight the significance of its evaluation for the design of locally adapted and sustainable parasite control and poverty alleviation programmes. We conclude by listing a set of research needs for future investigations.

Health diplomacy and the enduring relevance of foreign policy interests

Harley Feldbaum and Joshua Michaud consider the important interplay between foreign policy and global health interests, and introduce a series on Global Health Diplomacy beginning this week in PLoS Medicine.

Integration of control of neglected tropical diseases into health-care systems: challenges and opportunities

Although progress has been made in the fight against neglected tropical diseases, current financial resources and global political commitments are insufficient to reach the World Health Assembly's ambitious goals. Increased efforts are needed to expand global coverage. These efforts will involve national and international harmonisation and coordination of the activities of partnerships devoted to control or elimination of these diseases. Rational planning and integration into regular health systems is essential to scale up these interventions to achieve complete eradication of these diseases. Programmes with similar delivery strategies and interventions-such as those for onchocerciasis, lymphatic filariasis, and soil-transmitted helminthiasis-could be managed on the same platform and together. Furthermore, better-resourced programmes-such as those for malaria, HIV/AIDS, and tuberculosis-could work closely with those for neglected tropical diseases to their mutual benefit and the benefit of the entire health system.

Neglected tropical disease vaccines

The neglected tropical diseases or 'NTDs' represent the most common infections of the world's one billion poorest people. Unlike the better known acute or emerging infections, the NTDs are generally chronic and disabling (and often disfiguring) conditions. The long-term disability they cause has been revealed as a major reason why poor people in developing countries cannot escape the poverty trap. Because NTDs are associated with poverty, vaccines against these conditions are sometimes referred to as antipoverty vaccines. However, despite their global public health and economic importance, such vaccines have largely been ignored by industry and today are predominantly being produced through the activities of non-profit product development partnerships (PDPs). The Human Hookworm Vaccine Initiative based at the Sabin Vaccine Institute is one such PDP developing two antipoverty vaccines for hookworm and schistosomiasis, respectively. It has been proposed to combine these vaccines in order to target polyparasitic co-infections leading to severe anemia. Ultimately, to ensure global access of a multivalent anthelminthic vaccine, it may be linked to deworming programs through vaccine-linked chemotherapy. This would be an important step towards achieving the Millennium Development Goals for sustainable poverty reduction by 2015.