Capstone - Neglected Tropical Diseases 2

Table of Contents

Introduction

Neglected Tropical Diseases
Definition
Impact of NTDs
Characterization of “Neglect”

Focus: Buruli Ulcer, Lymphatic Filariasis, Leprosy
Buruli Ulcer
Leprosy
Lymphatic Filariasis
Obstacles to Care and Factors that Facilitate the Spread of NTDs

Prevention of Disease and Disability
Public Health Model: Levels of Prevention
Primary Prevention
Secondary Prevention
Tertiary Prevention

Poverty and Infectious Diseases
Environmental Factors
Limitations of Current Healthcare System
Stigmatization, Discrimination, and Cultural Barriers
International Policy and Neglect of Poverty

Implications for Pain Care in SSA and Recommendations for Future Action
Pain Implications of 3 NTDs
Recommendations for Pain Management
Recommendations to Address Stigmatization and Discrimination
Course of Action to Empower Affected Populations

Conclusion

Introduction

In the year 2012, the world’s population stands at 7 billion; out of this 7 billion, 1.4 billion live in extreme poverty, subsisting on less than $1.25 per day.^[1] According to the United Nations’ International Fund for Agricultural Development, 70% of the developing world’s extreme poor population still lives in rural areas, with nearly a third living in sub-Saharan Africa (SSA).^[2] SSA is a region that Oxfam depicts as a hurdler’s race, in which “the weakest athletes face the highest hurdles.”^[3] In sub-Saharan Africa, life expectancy is thirty years less than the United States; the rural sector severely lacks social infrastructure including clean water, food, job opportunities, and housing. Basic healthcare is plagued by a dearth of access to transportation, resources, and healthcare professionals.^[4] Within this climate and as a symptom of entrenched rural poverty, infectious diseases have become endemic to the region, affecting more than 500 million in rural sub-Saharan Africa.^[5] The proliferation and persistence of infectious diseases disproportionately affect rural sub-Saharan Africa and stand as a hallmark for the neglect of poverty in rural areas. While the eradication of these diseases is now an international policy objective and a global health pledge by Bill Gates and the WHO, there remains a need to alleviate the pain and human suffering associated with these diseases, and to support the development of infrastructure that will empower vulnerable populations.

Following the HIV/AIDS pandemic and the emergence of novel infectious diseases, many of which occurred in sub-Saharan Africa, global attention has turned to neglected tropical diseases (NTDs). NTDs are a diverse group of infectious diseases with symptoms that are extremely debilitating and disfiguring; the “neglect” of these diseases is characterized by a notable dearth of research, development, and interventions to address their prevention and treatment.^[6] NTDs are caused by pathogens that thrive in hot, humid environments and in areas where vectors are prevalent. These pathogens find a haven in the subtropical region of SSA, where intense poverty leaves populations vulnerable to a lack of access to clean water, adequate nutrition, housing, transportation, electricity, and primary healthcare.^[7] NTDs are most prevalent among the 500 million people classified as the extreme poor in sub-Saharan Africa, who live on less than $1.25 a day; in SSA, they carry a burden of disease of more than 56.6 million Disability Adjusted Life Years (DALYs).^[8] Peter Hotez, a global health expert and advocate, states that this burden is “equivalent to up to one-half of SSA’s malaria disease burden and more than double that caused by tuberculosis…the overall burden of Africa’s NTDs may be severely underestimated.”^[9] Research shows that no other continent in the world carries a burden of infectious disease equal in scope to the African continent.^[10]

Recently, there has been a shift in the world’s approach to fighting poverty and global health issues in low- and middle-income countries. NTDs are now accorded increasing attention. This concern for the increase in infectious diseases is manifested in an ambitious push by the Millennium Development Goals, which classify NTDs as a strategic priority, and in ongoing projects by the World Bank to address the economic impact of disease in debtor nations. These infectious diseases represent not only an issue of global health but also the deeply entrenched trends of inequality and neglect of populations; in the poor, rural areas of developing countries, these diseases become part of and perpetuate a cycle of poverty for individuals, families, and communities.

The increasing global focus on the health of the world’s most impoverished populations also extends to human rights organizations, advocacy groups, and academic institutions. This has resulted in an abundance of journal articles, scholarly discussions, and global forums on the impact of infectious diseases in developing countries, as well as a growing number of non-governmental organizations (NGOs) devoted to reduce the prevalence of poverty and disease in poor countries.

The impetus to solve the growing problem of endemic infectious diseases has brought large investments from American and British aid agencies and organizations to fund the production of chemotherapeutic agents to combat these diseases. These investments are coordinated by pharmaceutical corporations such as GlaxoSmithKline, who donate over a billion treatments per year.^[11] One example includes the $750 million investment for chemoprevention and treatment, which was recently given by the Gates Foundation to the Global Fund to Fight Aids, Tuberculosis and Malaria. This approach to mitigate the problem through funding and administration of chemical drugs has been challenged by recent concerns of field experts: according to an article in The Economist, “Bruno Gryseels of the Institute of Tropical Medicine in Antwerp fears that blanketing regions with medicines will make bugs drug-resistant.”^[12] While addressing short-term treatment needs is important to minimize the impact of infectious diseases, solving the long-term issues of global health requires the creation of sustainable solutions and a more collaborative process.

With the increased global attention and investments in chemical prevention, the subject of NTDs has not been neglected in recent years; however, the neglect of populations suffering disproportionately from these diseases and the structural issues that hinder environmental prevention have persisted. The focus of investment and international organizations on chemical treatment as a solution to issues of global health and particularly epidemic infectious diseases ignores the historic memory of the economic development in the West during the age of industrialization. Surveillance of diseases was critical in the development of early public health measures. The measures envisioned by Florence Nightingale and implemented by Dr. John Snow during the cholera outbreak in London during the 1880s formed a foundation to address environmental prevention as a primary component of healthcare. Adequate supplies of safe and potable water, enriched food sources, functional transportation and energy infrastructure, and access to basic healthcare became the sine qua non for population health; only once these elements were addressed were vaccines and chemoprophylaxis introduced for prevention and treatment.

This paper will specifically address three NTDs whose pervasiveness and impact represent a metaphor for neglect: lymphatic filariasis, Buruli ulcer, and leprosy. In addition to investigating the impact of these three diseases and the general nature of NTDs, this paper will also explore the capacity of sub-Saharan Africa and the international community to address structural issues that hinder prevention and treatment.

Neglected Tropical Diseases

Definition

The World Health Organization (WHO) defines neglected tropical diseases (NTDs) as “hidden” diseases, as they affect almost exclusively extremely poor populations living in tropical rural areas beyond the reach of health services.^[13] They comprise a diverse collection of primarily infectious diseases that thrive in the heat and humidity of tropical and sub-tropical climates. NTDs can have viral, protozoal, fungal, bacterial or filarial origins, and may be spread by insect or animal vectors – including mosquitoes, blackflies, snails, sandflies, and tsetse flies – or by contaminated water and soil infested with the eggs of worms. Their symptoms affect skin, nerves, lymphatic and subcutaneous tissue, causing lifelong, painful and disabling damage. They can also have an insidious onset, with severe impairments erupting after years of silent, subclinical infection.

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^[1] “We Can End Poverty 2015, The Millennium Development Goals.” United Nations. http://www.un.org/millenniumgoals. 3 Mar 2012.

^[2] United Nations International Fund for Agricultural Development. The Rural Poverty Report 2011. http://www.ifad.org/rpr2011/report/e/overview.pdf

^[3] “Who We Are and Might Be: In Global Health, Excellence Demands Equity.” American Journal of Kidney Diseases. Vol. 51, Iss. 1, Pages 145-154. Jan 2008.

^[4] O’Neill, Edward. “Who We Are and Might Be: In Global Heath, Excellence Demands Equity. American Journal of Kidney Diseases, Volume 51, Issue 1.

^[5] Hotez, PJ and A Kamath. “Neglected tropical diseases in sub-Saharan Africa: review of their prevalence, distribution, and disease burden.” PLoS Neglected Tropical Diseases. 5 Aug 2009.

^[6] Jamison, DT, JG Breman, AR Measham. Priorities in Health. World Bank: Washington DC, 2006.

^[7] Manderson, L, J Aagaard, P Allotey, et al. Social Research on Neglected Diseases of Poverty. PLoS Negl Trop Dis. 3(2):e332. Global Climate Change for Africa Project 1998. 24 Feb 2009. http://www.worldwildlife.org/bsp/bcn/learning/african/gcc1.htm

^[8] Boutayeb, A. Developing countries and neglected diseases: challenges and perspectives. International Journal for Equity and Health. 2007.

^[9] Hotez, PJ and A Kamath. Neglected Tropical Diseases in Sub-Saharan Africa: Review of Their Prevalence, Distribution, and Disease Burden. PLoS Negl Trop Dis 3(8):e412. 25 Aug 2009.

^[10] Ibid.

^[11] “Neglected Tropical Diseases Hot Topic – the world’s nastiest illnesses get some belated attention.” The Economist. 4 Feb 2012.

^[12] Ibid.

^[13] “Working to overcome the global impact of neglected tropical diseases: First WHO Report on Neglected Tropical Diseases.” World Health Organization. 2010.