By: Alanna Shaikh
A new paper on NTDs covers the current debate on the best approach for combating them. Should we focus on mass drug administration? Environmental approaches? Horizontal programs? Written by Jerry M. Spiegel, Shafik Dharamsi, Kishor M. Wasan, Annalee Yassi, Burton Singer, Peter J. Hotez, Christy Hanson, and Donald A. P. Bundy, the article brings together respected experts on neglected tropical diseases to identify the most effective ways to fight them. Not surprisingly, these experts don’t agree. They propose substantially different methods to reduce the impact of NTDs.
All the authors make interesting points. Jerry Spiegel, Shafik Dharamsi, Kishor Wasan, and Annalee Yassi are proponents of addressing the social determinants of NTDs, and they make some fascinating, radical arguments. They cite an excessive focus on developing new drugs, and state that it “diverts attention and funding away from complementary strategies needed to sustainably reduce disease burden…” They go on to call for a new financing mechanism for addressing the root causes of NTDs: “We propose that whenever a research program on an NTD innovation is funded, a proportion of the funding is set aside (‘‘offset’’) to address related socio-environmental and health system aspects.”
On the other hand, Peter J. Hotez, Christy Hanson, and Donald A. P. Bundy argue for integrated control of NTDs based on mass drug administration. They couch their case in effectiveness terms “In terms of both health impact and cost-effectiveness, few other interventions can rival mass drug administration for NTDs, and increasingly this approach is being recognized for its beneficial effects on strengthening health systems, improving economic development, and achieving the Millennium Development Goals.” They then describe the progress made in NTD control as a result of drug administration. Their pick for the most effective approach is integrated control of NTDs; in other words, administering the drugs for more than one NTD at a time. That avoids unnecessary duplication of logistical and personnel efforts.
Burton Singer, arguing for primary prevention of NTDs, has two excellent quotes. First, he points out that “You don’t find a demand for drugs to treat hookworm in the southern United States today, because an integrated program of drugs to treat infected cases and installation of toilets (a tool for prevention) as a route for human feces—initially containing hookworm eggs—put an end to the problem almost a century ago.” He goes on to state that “nearly half of the measurable population-level health improvements in sub-Saharan Africa in the 1990s were a consequence of positive inputs in water and sanitation, housing, transportation, and communication…”
I have a tendency to come out of discussions like these agreeing with every side, and this paper is no exception. I am not sold on social offsets. Beyond that, though, I agree with everyone. Drug administration works. It works right away, and it can be organized with a minimum of host country capacity. If you want to make a rapid dent in the human impact of NTDs, mass drug administration is the answer. At the same time, primary prevention is key to long-term impact. Burton Singer is right -- we don’t have a whole lot of NTDs in the US, and it’s not drug administration that got us to this point.
The thing is, the different approaches aren’t mutually exclusive. You can do both mass drug administration and primary prevention. In fact, that would be the best approach -- if we had enough funding for it. What we really have here is a more pie situation. And we can all fight for more pie for NTDs.
Alanna Shaikh is an expert in health consulting, writing about global health for UN Dispatch and about international relief and development at Blood & Milk. She also serves as a frequently contributing blogger to ‘End the Neglect.”