By David Molyneux
The current Global Ebola crisis presents a multitude of challenges in terms of our capacity to respond; the future is even less predictable. Statements from the World Bank President and the Director General of WHO highlight the potential devastation of Ebola: its long term economic and social impact and the reasons for the epidemic spread - the neglect of the health services and lack of human capacity. The three countries affected: Sierra Leone, Liberia and Guinea have recently made significant progress in controlling Neglected Tropical Diseases. Conditions such as river blindness, elephantiasis and schistosomiasis (bilharzia) have been eliminated in areas of Sierra Leone while river blindness projects in Guinea and Liberia have been effective. Other NTD programmes were being initiated through various donor agencies to build on this success but progress is dependent on the control of Ebola.
NTDs are chronic infections that indiscriminately afflict the poorest, with least access to the rudimentary health care services in rural areas but the success of the NTD programmes has been driven by community involvement in the distribution of donated drugs and through school based deworming programmes. NTD mass drug distribution has been described as the best investment of health dollars for any health intervention, with delivery costs of 20-50 US cents per person/year. Success of these programmes requires the annual or bi annual distribution of high quality donated drugs as well as the availability of health workers at the district level. In countries with already limited human capacity in the health sector NTD programmes will regrettably be curtailed as Ebola has taken hold in the very communities where sustained annual drug distribution is required. Volunteer health workers trained by NTD programmes are likely to be on the Ebola frontline, trusted as they are by communities to deliver health advice through their involvement in numerous programmes.
The emergence of Ebola from an animal source with biological characteristics of high infectivity, a long incubation period and high case fatality rates requires special measures which even in the most sophisticated “first world” health centres of Madrid and Dallas do not prevent transmission amongst health care workers with an intimate knowledge of risk. In contrast the people at the epicentre of the epidemic are unlikely to be spared infection as they not only lack the knowledge of the basic risks but have no health system to support them. Many of these communities are beyond the end of the road; with limited communication, few or no government services and communities structured through the traditional and secretive belief systems which command total respect of the population making them potentially reluctant to adopt the recommended approaches to infection control even if the risk is appreciated. Health Education at the scale required to arrest transmission is hugely optimistic, given clinical staff tend the sick as the priority.
NTD programmes, however, have reached these populations. The river blindness programme distributing ivermectin through community directed treatments has delivered over 40 million treatments annually to communities more than 20 km from the nearest health facility. Communities affected by Ebola are also currently beyond the end of the road as far as reach is concerned. Few in the developed world appreciate the logistic and communication problems facing any health activity in such settings but NTD programmes, because of the use of communities, have overcome that challenge but this has taken many years of significant investment by a coalition of partners.
By 2050 it is estimated that 50% of the world population and 60% of world’s children will be living in the Tropics, but currently only 0.6% of overseas development assistance for health is allocated to NTDs. The current Ebola outbreak together with the wider impact of conflict, environmental degradation, climate change and the frequency of natural disasters put the progress made against NTDs under significant threat. Yet NTDs are markers, agents and drivers of poverty of over a billion of the poorest. Controlling and eliminating NTDs can make a proportionately greater contribution than any other investment – more health for less money. This policy message needs to be further articulated based on strong scientific evidence and programmatic success.
David Molyneux. Emeritus Professsor and Senior Professorial Fellow LSTM.