Ending ‘invisible diseases’ of ‘invisible people’: Germany’s contribution to the fight against Neglected Tropical Diseases
Patients with lymphatic filariasis in Tanzania waiting in a health centre in Dar es Salaam ©DNTDs/g+h communication
Nearly a quarter of the world’s population suffers from just 20 profoundly disabling tropical diseases, that have largely managed to stay ‘under the radar’. Germany is a major player in a fresh global effort to shine a light on the Neglected Tropical Diseases and overcome their ravages.
Hidden under a long taffeta skirt and fluffy red slippers, her deformed lower limb is kept out of sight, as the shy young woman sits in line, waiting to be seen by a health provider. Lymphatic filariasis commonly known as elephantiasis, is a painful, foul-smelling and disfiguring disease that afflicts over 50 million people in tropical countries. Caused by a parasite transmitted by mosquito bites that invades the lymphatic system, it has been a disease of ‘invisible’ people, lacking the means and knowledge to protect themselves, and too poor to attract attention and support for their dilemma. Lymphatic filariasis is a Neglected Tropical Disease (NTD), one of 20 estimated by the World Health Organization (WHO) to affect some 1.7 billion people – nearly a quarter of humanity. NTDs include diseases as varied as schistosomiasis (bilharzia), onchocerciasis (river blindness), leprosy, trachoma, sleeping sickness and rabies. Sometimes lethal, often disabling and always stigmatising, the NTDs’ burden on physical and mental wellness, school attendance and social and economic progress is immense.
Like many of the NTDs, lymphatic filariasis is easier to prevent than to cure. Mass administration of drugs in endemic regions can interrupt community transmission of the parasite and halt progression of the disease in those already affected, but these individuals will have to live as best they can with their deformity, e.g. keeping it clean and using compression stockings where practicable.
Ending ‘the epidemics of … neglected tropical diseases’ by 2030 is Target 3.3 of the Sustainable Development Goals (SDGs) and the objective of WHO’s 2021-2030 Road Map for NTDs.
The 20 NTDs
Germany’s stronger focus on the NTDs
Two years into the COVID pandemic, Germany’s new government is laying a renewed priority on health, including in its development cooperation. Reinforcing efforts against the NTDs is part of this. In January Germany was the first Western nation, after Rwanda, Nigeria and Tanzania, to sign the brand-new Kigali Declaration, a commitment of partner countries and other crucial stakeholders from industry, science, multilateral organisations and NGOs to implement WHO’s Road Map to end NTDs by 2030.
On March 31 the Sector Initiative One Health of the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), in collaboration with the Federal Ministry for Economic Cooperation and Development (BMZ), will be hosting a gathering of NTD key players and practitioners from German development cooperation to share WHO’s new Companion Document to its Road Map. This will be an opportunity to reflect on how to integrate its holistic approach in existing programmes in Germany’s many partner countries.
A vibrant community of practice
The German NTDs Network (D-NTDs) is a vibrant community of practice founded in 2014 under the international umbrella organisation Uniting to Combat NTDs (UCN), bringing together eminent specialists from Germany’s universities and research institutes, pharmaceutical industry and civil society, including overseas aid agencies such as the Christoffel Blindenmission (CBM). Through their publications, their ‘Fireside chats’ on World NTD Day (January 28), and their interactions with Parliament and Government, the network contributes to visibility for the NTDs.
A roundtable for European partners committed to ending NTDs
On April 26, at the request of Uniting to Combat NTDs, the BMZ will organise a Neglected Tropical Diseases European donor roundtable around the Kigali Declaration, to reinforce planning and coordination of the different European countries’ contributions – from public sector to start with – to implementing the NTD Road Map, including consideration of the One Health approach. Germany will also use its current 2022 presidency of the G7 to promote the cause of the NTDs. A meeting in May on Global Health between G7 health and development ministers will focus on global vaccination efforts against COVID-19, but also discuss the development of new vaccines against other infectious diseases, including NTDs.
Onchocerciasis patient Hawa in Nigeria. ‘River blindness’ is transmitted by the bite of a blackfly that breeds near fast-flowing streams
COVID taught us about stigma and disease
Says Dr Daniel Eibach, of BMZ’s One Health Division, ‘The COVID pandemic has been a wake-up call for our rich Western nations: We have been shaken by this sudden confrontation with a devastating, stigmatising disease – but this is what people in our partner countries are dealing with every day with the NTDs.’
On the one hand the COVID pandemic deepened the neglect of the NTDs, siphoning away attention and funding from these largely invisible diseases, but on the other hand the need to come together to combat the global challenge of COVID has also created a new world of opportunities for global and intersectoral cooperation (see WHO 2021). The lack of medical treatment for COVID patients also forced a worldwide shift in perspective to prioritising preventive measures as the only way out of the pandemic.
COVID, like most of the NTDs, is a zoonosis, a disease spread from animals to humans. The COVID pandemic has been a powerful argument for a new, holistic view of human health as indissociable from animal health and the ecosystem. This ‘One Health’ perspective has inspired WHO’s new companion document to its 2021-30 Road Map and is enshrined in BMZ’s 2021 One Health strategy.
One Health: the new paradigm to tackle the NTDs
The 2019 Berlin Principles on One Health recognise that ‘Human, animal, plant and environmental health and well-being are all intrinsically connected and profoundly influenced by human activities.‘ This is particularly true for the NTDs, most of which are caused by parasites, bacteria and viruses which breed in conditions of poor hygiene, lack of clean water, and where humans and animals live in close proximity. The One Health approach implies integrated actions of complementary stakeholders from different sectors, particularly for greater efficiency of preventive measures, e.g. in water, sanitation and hygiene (WASH) or – as was done in a GIZ project in Cameroon – getting a veterinarian to vaccinate not only dogs (against rabies) but also chicken, sheep and goats at the same time. In addition, affected communities, including in remote places, need to be informed about NTD risks and causes, in order to empower and enable them to protect themselves.
The One Health approach, as Dr Eibach explains it, also means actively looking for synergies among existing programmes (e.g. working with community workers that are already in place rather than selecting and training new ones), as well as for gaps in the response that need to be filled – for instance, in research or in vaccine availability. It also means leaving behind inefficient vertical programmes that target a single NTD in isolation. It can make sense to group together certain NTDs (e.g. those affecting the skin) with characteristics in common that make them amenable to a similar approach.
On the ground with ESPEN
In December 2021, GIZ’s Global Programme ‘Pandemic Prevention and Response, One Health’ signed a grant agreement to support WHO’s Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN) in integrating the One Health approach into their work. Based in WHO’s regional office for Africa in Brazzaville, ESPEN focusses on the five most prevalent NTDs (lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminthiases and trachoma), which together account for 90% of the documented NTD disease burden in Africa. What these five diseases have in common is that they can be effectively prevented by mass drug administration in the communities at risk. In addition, other preventive low-cost measures can help avoid infections in humans, such as improved WASH, local animal health services – mainly vaccinations and deworming for livestock or dogs – or health education and awareness raising. The importance of One Health – looking at human and animal health as part of a whole – is illustrated by the challenge national NTD programmes face in organising mass drug administration against schistosomiasis while avoiding severe side effects of the medicine on people with neurocysticercosis as a result of co-infection with the larvae of the pork tapeworm.
Underreporting is another major challenge for controlling the NTDs: For instance, it is estimated that barely 1% of rabies cases are reported. This means that unreported NTDs could have an even higher share in the overall burden of communicable diseases than we are aware of.
Country ownership of the programme is crucial
Through WHO’s network of country offices, national governments are supported in surveillance and mass drug administration for eradicating the NTDs that affect their countries. Trainings for the health work force, including community health workers and community animal health workers, as well as awareness-raising activities that target the communities at large, complement these measures.
ESPEN medical officers such as Dr Amir Kello and Dr Pauline Mwinzi have an intricate task coordinating the fight against these five NTDs on many different fronts: epidemiological research and mapping to establish the profile of each country, guidance to the national health ministries, including on environmental and cross-sectoral measures, watching out to avoid potential drug interactions, organising laboratories and distribution chains, as well as appropriate training for community drug distributors, keeping health statistics up to date, and following the different countries’ progress on the path to elimination of ‘their’ NTDs. Since 2010 and WHO’s first NTD roadmap, worldwide 42 countries, territories and areas have already eliminated at least one NTD.
‘What is crucial,’ says Pauline Mwinzi, ‘is country ownership of the programme – and health system strengthening. In many countries, the elite do not see the problem because the poor are invisible. So the needs of poor, isolated and remote people, including the NTDs that plague them, are not even addressed by the existing health and other governmental services’ system. The NTDs need to be recognised, and their treatment and prevention need to be integrated as part of primary healthcare.’
Germany supports a holistic approach to ending NTDs
Dr Eibach sums up: ‘We have a systemic and holistic approach, focussed on overall health systems strengthening rather than on combatting individual NTDs. They are integrated into our One Health strategy, in which we give priority to prevention and synergies among different sectors such as WASH, agriculture and veterinary medicine.’
‘What is most important is that NTDs not again be neglected in the context of COVID. In fact, many of these diseases could quite easily be prevented if the international community jointly supported measures in the most affected countries. Crises are our most effective teacher, and with COVID the world has brought the lesson home to us! That is why health is again a top priority – and that includes the NTDs.’
Dr Mary White-Kaba