The fight against neglected tropical diseases

African countries with modest national incomes are outperforming some richer nations on the continent in the fight against diseases of poverty known as neglected tropical diseases (NTDs), according to a new league table ranking.

NTDs such as blinding trachoma, the leading cause of infectious blindness, or intestinal worms that can stunt growth in children, are endemic in poor communities without access to clean water and with inadequate sewerage systems. The diseases affect 1.6 billion people worldwide – that’s one in five on the planet – including over 600 million people in Africa.

The league table ranks the countries according to their performance in reaching everyone in need with the necessary treatment, across the five most common NTDs in Africa that are amenable to mass treatment. The countries treating the highest proportion of those in need across all five diseases rank highest in the table.

The table shows that three countries with modest national incomes – Malawi, Sierra Leone and Togo – have, for the third year running, reported high treatment levels to those in need across the five diseases. The WHO reckons that if countries consistently treat and protect more than 75% of people needing care, across the five diseases, they are on track to beating the diseases. Malawi, Sierra Leone and Togo all reached the 75% average target.

All three nations are in the ‘lower income’ bracket of the UN Human Development Index, a broad measure of national wealth.

Richer African countries with a higher UN Human Development Index such as South Africa and Equatorial Guinea (both ‘medium income’ by the UN measure), or Gabon and Botswana (both ‘higher income’ according to the UN) were all ranked in the bottom third of the disease fighters’ league table.

However, Botswana looks set to change this with its late 2018 pledge to use its own domestic resources to eliminate all neglected tropical diseases found within its borders, starting in 2019.

Botswana joins Mozambique which made a commitment at the same time, in its case, to allocate US$6M of domestic resources to fight NTDs. Most endemic countries receive outside help for their elimination programmes. We hope to see an increase in the levels of funding coming from domestic sources for fighting these diseases.

The highest-ranking country in this year’s disease-fighters league table is eSwatini (the former Swaziland).  While the number of people in need of treatment in eSwatini is much smaller than, say, Nigeria, eSwatini still scores highly because of its commitment to reach every individual in need of treatment.

The five most common NTDs amenable to mass treatment are: blinding trachoma; intestinal worms; the mosquito-borne elephantiasis; snail-borne bilharzia; and river blindness.  All five can be prevented or treated with medicines that are donated for free to endemic countries by pharmaceutical companies.

NTDs rarely make headline news because they tend to afflict the poorest and most marginalised communities. However African Heads of State have put a spotlight on them at the current AU Summit through the African Leaders Malaria Alliance (ALMA), a forum that tracks the fight against malaria and, since 2018, also reviews the fight against NTDs.

NTDs were once prevalent throughout the world, including in western countries. But they are now almost exclusively endemic in developing nations. They are known as diseases of poverty because they thrive in communities with few resources and also perpetuate low income by limiting the ability of individuals to work and go to school. They cause disability and stigma and can even lead to death.

However, considerable progress has been made against NTDs. In 2018, Ghana passed a milestone:

“In 2018, we became the first sub-Saharan African country to eliminate blinding trachoma, a painful and debilitating disease”, said President Nana Akufo-Addo;

“We cannot achieve the Sustainable Development Goals without addressing the needs of the poorest members of our society who are disproportionately affected by neglected tropical diseases. I urge my fellow African leaders to prioritise ending these diseases of poverty on the continent”, President Akufo-Addo added, concluding;

“We have shown it can be done.”

The number of people in need of treatment for NTDs has fallen since 2015, the year heads of state adopted the sustainable development goals in which NTDs were specifically mentioned as a target. Over the same period, the proportion of people receiving treatment compared to those in need, has risen.

In Sub-Saharan Africa alone, there were 630 million people in need of treatment for at least one NTD in 2015. By 2017 this had fallen to 605 million – a drop of 25 million in just three years, showing that treatments for NTDs are effective.

This is a step in the right direction towards meeting the sustainable development goal for NTDs, which is to reduce the number of people in need of treatment for NTDs by 90% by the end of 2030.

In 2015 the proportion of the 630 million people in need of treatment in Sub Saharan Africa who received it, was just over half, or 51%. By 2017 this proportion had risen – 68% of the 605 million people in need were getting the drugs they required.

The success is due, in large part, to the commitment and leadership of the WHO Regional Director for Africa, Dr Rebecca Matshidiso Moeti, who set up a dedicated project in the regional office called the Expanded Special Project for the Elimination of Neglected Tropical Diseases (ESPEN) which has been working with countries, providing technical and implementation support.

But despite these successes, the number of countries in Africa that are being validated by WHO for achieving elimination of these diseases is still far below the rest of the world. There is real potential for Africa to take leadership in this area and succeed. Unless this is done, NTDs will continue to cause pain, disability, disfigurement and stigma for millions of people in Africa, and will continue to rob developing economies of billions of dollars-worth of productivity gains.