Four acts in 90 minutes. A tight script that does not leave time for clapping. Nine men in dark suits and one woman on stage. That one woman is Margaret Chan, Director General of WHO. One of the men is Bill Gates. The stage is Uniting to Combat Neglected Tropical Diseases (NTDs), an event convened by WHO and the Bill and Melinda Gates Foundation.

The first act: ‘Setting the stage’. This is the most comprehensive, coordinated action ever to address NTDs. “I have never seen so many competitors working together”, said Margaret Chan, referring mainly to the 13 large pharmaceutical companies present, but possibly also referring to the bilateral and multilateral donors. The prospect of elimination appeals to many.

An animation lays out what it is we are combating; ten circles, representing ten ancient parasitic infections which affect over 1 billion of the poorest and most neglected people. The ten circles move into two groups; seven versus three. For the seven – Guinea worm (eradication), lymphatic filariasis (elimination), leprosy (elimination), trachoma (elimination), schistosomiasis (control), soil-transmitted helminthes (control) and river blindness (control) – the battle can be geared up relatively easily. The tools and strategies already exist and for most of the seven these are simple and among the most cost-effective interventions in public health: periodic mass drug administration of cheap tablets and improving water and sanitation. But the other three, visceral leishmaniasis, human African trypanosomiasis (sleeping sickness) and Chagas disease, require new tools and strategies to make elimination/control possible.

In Médecins Sans Frontières’ medical programmes we see the need for these new tools and strategies every day: for rapid diagnostic tests, oral effective treatments and support to heavily under-resourced national control programmes. For sleeping sickness in particular, endemic countries are almost all failed and insecure states. ‘Sleeping sickness lives in the last village’, as a member of a national control programme in central Africa once said to my colleague. The national sleeping sickness programmes in most central African countries have few staff members, and worse, they can work only in parts of the year when there is money for fuel, transport and salaries. For sleeping sickness to be eliminated, enhanced research and development (R&D) and programmatic support along with access to current drugs are necessary. The actors at the London conference were offering only the latter. Now is the time to address the reality. It is urgent.

Act two featured making progress with existing tools, while act three ushered in innovation and new tools. ‘There is a today and there is a tomorrow’, said a CEO of a large pharmaceutical company. Today has a huge unmet need. Tomorrow is where R&D comes in. And, as another CEO said, ‘here is where the secrets are’. Indeed. The commitment made at the event by 13 large pharmaceutical companies to share and open up data and compound libraries is welcome news. But more attention went to announcements on branded drug donations; several existing donations will be increased or extended until 2020. Noble and useful actions – that should be seen in perspective. For example, MSD has, since 1981, annual sales of ivermectin for veterinary use of about $1 billion. Perhaps it is only fair to make it free for humans? For a few drugs, generic production would be better. No word on that in the script, though it was generic production (only) that made sustained and dramatic scale-up of access to antiretroviral treatment for HIV possible.

The last act: ‘Realizing the 2020 goals’. The story here was how to connect drugs and people, a simplified version of health systems strengthening; a score card needed to measure progress and impact; how to reach those most in need; the need to engage countries and coordination by ministries of health; creating a critical mass and tipping point. More questions than answers, but fair enough, this is just the start.

So, here is where we are. A common call to action and a road map to elimination and control of ten NTDs by 2020. History in the making, I hope. And I hope that the remaining essential steps will be executed with the same enthusiasm: include companies who develop diagnostic tools, get the political commitment of endemic countries, steer and heavily invest in national NTD control programmes, establish strong leadership of the initiative, measure progress and impact, build capacity to sustain the successes, and keep focus.

Rachel ter Horst, MSF

Rachel ter Horst is a Dutch physician who has worked for Médecins sans Frontières since 2003. She is currently serving as a medical advocacy advisor, based in Amsterdam.

Image Credit: James Gathany, Centers for Disease Control and Prevention

Author: Renata Santillan

The current issue of PLoS Neglected Tropical Diseases presents a new collection of articles on the use of genetically modified (GM) insects for controlling some of the most widespread infectious diseases. Articles from across the PLoS journals describe the technological advances these tools represent, the regulatory framework, and the societal dialogue that is necessary for their wide-scale application for disease control.

Diseases transmitted by insects form a huge burden on human and animal populations. Insect control has historically been one of many strategies for control of diseases such as dengue, malaria, and sleeping sickness. The debate on whether GM insects could be used for disease control began as soon as transgenic insects were first produced in the 1980’s. Since then several experimental releases of GM insects have taken place. These trials show promise for limiting the spread of many vector-borne diseases (most notably Dengue fever). Articles in this collection showcase different aspects of this new technology including development, environmental impact, and regulation. Public discussion of the science and application of GM insects is necessary as new developments bring potential wide releases closer to a reality.

In an Editorial, Drs. Michael J Lehane (Liverpool School of Tropical Medicine) and Serap Aksoy (Yale School of Public Health) state that GM insects “may provide great promise for new means of controlling diseases with a devastating impact on people’s lives. If so, then public acceptance is likely to be a key issue in their implementation.” With many countries considering open field trials of GM insects, a Viewpoint by Guy Reeves et al. examines the regulation process of the first 3 countries that have had field trials of GM insects. Commentary by John Mumford highlights that both national and international regulations are required due to factors regarding each country’s individual environmental risk to GM insects.  In a commentary from an industry perspective, Luke Alphey and Camilla Beech argue that “the agencies tasked to regulate GM insects have appropriately taken a cautious, thorough approach that allows progress towards realisation of the substantial benefits GM insect technology could potentially provide, while rigorously protecting the public and environment.”

The articles in this collection highlight many different points of view surrounding the research into GM insects. As the recent history of GM insect development demonstrates, public discussion is necessary as scientists continue to research GM insect technologies to control some of the world’s most devastating diseases.

Over 1 billion people practice open defecation. (Image credit: Rémi Kaupp; wikimedia commons)

Diarrhea, abdominal pain, malaise, anemia, and delayed child development: these are the debilitating effects of one group of diseases, the soil-transmitted helminths (worms). As indicated by the name, these diseases are transmitted via contaminated soil; as such, good sanitation has a key role in prevention. However, because sanitation systems vary greatly, their impact is difficult to study. Now, a PLoS Medicine systematic review and meta-analysis (a reanalysis of data from already published studies), by Ziegelbauer and coauthors, quantifies the benefits of sanitation: for all three of the STHs, when sanitation was both available and regularly used, the odds of getting a worm disease was cut in half.

One billion of the world’s people experience a diminished ability to work, learn, and thrive as a result of infection by these parasites  – roundworm, whipworm, and hookworm. The resulting losses in quality of life and productivity can trap people in a cycle of poverty and stigma and diminish their ability to care for themselves and their families.

Currently, the primary approach to the problem is repeat drug treatment. As important as drugs are, though, they also have limitations: reinfection in endemic areas; possible reduced efficacy and development of resistance; and supply, delivery, and compliance problems. Drug administration can go only so far, and currently many programmatic goals are not being met. For the STHs, many authors argue that integrated control is the only hope for lasting improvement (see Further Reading).

Integrated control of infectious diseases involves not only drug treatment to knock down the illness itself, but preventive measures such as education of at-risk communities, surveillance and research, strong healthcare systems, vector control, safe water supplies, good hygiene practices, and adequate sanitation systems.

Thus, Ziegelbauer and coauthors urge, drug treatment should be only part of efforts toward STH control; sanitation should also be emphasized. And the authors point out something that drug treatment does not do: “Implementation of sanitation facilities and integrated control approaches go far beyond the prevention and control of intestinal helminths; they impact other neglected tropical diseases, such as schistosomiasis, trachoma, and diarrhea…and can even help promote social and educational advances for women and girls…”

Policy and funding support for integrated control that includes good sanitation should be a focus as the world fast approaches the deadline for the Millennium Development Goals with disappointing progress toward #7C (to “Halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation.”).

Further Reading

Hotez PJ (2008) Hookworm and poverty. In: Reducing the Impact of Poverty on Health and Human Development: Scientific Approaches. Ann NY Acad Sci 1136: 38–44.

The 2010 PLoS Water and Sanitation collection

WHO: Water Sanitation and Health

WHO / UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation

Ziegelbauer K, Speich B, Mäusezahl D, Bos R, Keiser J, et al. (2012) Effect of Sanitation on Soil-Transmitted Helminth Infection: Systematic Review and Meta-Analysis. PLoS Med 9(1): e1001162. doi:10.1371/journal.pmed.1001162

Guest blogger Dr Michael Ekuoba Gyasi discusses trachoma, and the implications of two trials recently published in PLoS Medicine evaluating the treatment of minor trichiasis.

Trachoma is caused by Chlamydia trachomatis and is a leading cause of infectious blindness. In endemic communities the disease normally runs a chronic course with two distinct stages. The active stage occurs mainly in children under ten years who experience inflammation of the eyelids and discharge from the eye. The second stage occurs mostly in female adults. This is believed to be due to their close association with children, who serve as the reservoir for C. trachomatis, leading to cycles of re-infection and healing. With the ensuing chronic inflammation of the tarsal conjunctival tissues the lid margins turn inwards (entropion) and the lashes eventually touch and rub the surface of the globe (trichiasis) leading to corneal opacification and visual impairment.

Trachoma has been eliminated in most parts of the developed world but the disease remains a major cause of avoidable blindness in many developing countries.  At the global level the disease is concentrated in hot, dusty, and dry parts of the world stretching from Africa, through the Middle East to the Indian sub-continent and Asia with some pockets in Latin America. In endemic countries, it is found in rural areas that are economically underdeveloped with limited access to water and generally low level of personal and environmental hygiene.

As an infectious disease, trachoma clusters at the household and community levels with different severity and different potential for blindness. Ocular discharges containing the Chlamydia organism are the main sources of infection, which is transmitted through fomites (any inanimate object capable of carrying an infection), contaminated fingers and, more importantly, the eye-seeking common housefly, muscae sorbens.

The World Health Organization currently estimates that Trachoma accounts for 3.6% of global blindness burden and a control program, the SAFE strategy is being implemented in affected countries under the tenets of Vision 2020, the Right to Sight initiative. While there has been considerable success in the control of active trachoma in many endemic countries, the same cannot be said of the vision-threatening inactive form of the disease. The many reasons for this include inadequate number of surgeons trained to perform lid-rotation surgery, high recurrence of operated cases, low acceptance of corrective surgical procedures and socio-cultural issues among others. It is in this light that any attempts aimed at increasing surgical uptake, improving success and exploring alternative solutions should be commended.

A recently published high-powered control study by Rajak and co-workers has shown that using absorbable sutures (polyglactin-910) for tracomatous entropion surgery is as good as using conventional non-absorbable silk sutures.  Using the same surgical techniques, the authors found no difference in recurrence rate between the two sutures, even though there have been previous reports favouring lower recurrences for polyglactin. Since polyglactin sutures are absorbable and thus can be left in-situ, they offer major advantages in the operational sense; removing sutures is less of a burden for patient and surgeon freeing time to move on with other surgeries. It also allows surgeons enough time to assess surgical outcome and potential for recurrence. The main drawback however, is the cost and availability of polyglactin sutures in many of these impoverished countries where trachoma is endemic. Control programs will have to make budget allocation for this or persuade the manufacturer (Ethicon) to make donations in the same way as Pfizer and others do for azithromycin.

While surgical management of entropion is the gold standard for preventing cornea opacification and visual impairment, high recurrence rate, limited access, economic and socio-cultural barriers prevent many trachoma patients from accepting surgery in all cases. An alternative approach that is effective, easy to deliver and culturally acceptable therefore becomes important. This is why a sister article by Rajak and colleagues looking into the inferiority of self-epilation to standard surgical management of mild trichiasis is worth reading. Though inconclusive, there is enough evidence that self-epilation could be a viable alternate approach to the prevention of trachomatous corneal blindness.

Dr. Michael Ekuoba Gyasi is Medical Director of the North Western Eye Centre and Head of Clinical Care and Research at the Emmanuel Eye Centre in Accra, Ghana.

Visceral leishmaniasis (VL), a protozoan disease transmitted by sandflies, is the second-biggest parasitic killer worldwide (after malaria). In Ethiopia, the host country for the ICASA 2011 conference, VL and especially HIV/VL co-infection are major public health problems: more than one in three Ethiopian patients with VL is also HIV-positive, the world’s highest co-infection rate.

Treatment of HIV/VL patients presents serious challenges. The two diseases create a vicious spiral: HIV infection increases susceptibility to VL more than 2000-fold, and infection with VL accelerates progression to AIDS. VL is much more difficult to treat in patients with HIV, and even when initial treatment succeeds, patients usually relapse. While there are various drugs available for treating VL, all have drawbacks—for example, sodium stibogluconate (SSG) is highly toxic, particularly in HIV/VL patients (16-33% mortality during treatment) [1,2]; miltefosine is teratogenic; and resistance to drugs is a growing problem, especially when using monotherapy. Liposomal amphotericin B (L-AmB, currently registered as AmBisome®) is safe but must be given intravenously, and is prohibitively expensive for many settings. All these drugs show lower efficacy in HIV/VL patients.

As a physician with Médecins Sans Frontières (MSF) I spent two years living and working in Ethiopia, first in Humera, a hot, dusty border town, where MSF teams treated thousands of people with VL and HIV over the program’s 11 years.

Migrant workers in Humera, working and sleeping unprotected from the sandflies.

Here and elsewhere we worked towards better treatment for HIV/VL patients, and in a late-breaker oral presentation at ICASA I presented new data on outcomes of an alternative drug combination regimen and gave an overview of MSF’s experience managing HIV/VL patients in Ethiopia.

A combination treatment that improves on monotherapy
The main news was hopeful. In 2010 MSF introduced a new combination treatment, after evaluation of high dose L-AmB monotherapy in HIV/VL patients showed disappointingly limited effectiveness in HIV co-infected patients (32% parasitological failure) [3] and unacceptable mortality (16%) during “rescue” treatment of these patients with SSG. But in 50 patients treated with L-AmB (30 mg/kg) plus miltefosine (28 days), results were significantly better: initial cure rates of HIV/VL relapse, which is notoriously difficult to treat, were 87%, compared to 38% with L-AmB monotherapy (p<0.001). In 2012, MSF and several partners [4] will launch a randomized trial of the 2-drug combination, as well as higher-dose (40 mg/kg) L-AmB monotherapy, in co-infected patients.

Impact of ART on outcomes
Cellular immunity is vital for suppressing remaining parasites after VL treatment. While I was in Ethiopia, we demonstrated that ART in HIV/VL patients improves CD4 cell reconstitution only partially. Patients who had a VL relapse fared worst [5]: their CD4 levels never increased above 100 and VL relapses kept coming. Based on these findings, MSF now starts HIV/VL patients on ART as soon as possible after (first) VL treatment, regardless of CD4 count. Because ART alone is not adequate to prevent VL relapse, MSF and partners will soon begin a prospective study of secondary prophylaxis using monthly pentamidine injections.

Implications for HIV programs
MSF’s experience with VL and HIV/VL patients has important implications for HIV programs in VL-endemic countries. Donors and national HIV programs in these regions should include interventions that scale up VL prevention (e.g., impregnated bednets), diagnosis and optimal treatment. Access to early ART for those most vulnerable to VL, including rural migrant laborers and migrated populations, should be improved. In HIV-positive patients infected with the VL parasite but still asymptomatic, early use of ART may be the best way to prevent re-activation of latent VL. SSG should be avoided (due to its extreme toxicity) and high-dose L-AmB-based combination treatments given until parasitological cure is achieved, with ART added as soon as possible. And VL-endemic countries should add VL as in indication for ART initiation, irrespective of CD4 count.

Access to treatment
Access to L-AmB is a major challenge, mainly due to its high price. The recent AmBisome® donation agreement is significant in that it helps advance immediate treatment for one of the world’s most neglected diseases in four least-developed countries. But much more is needed to ensure long-term affordability and widespread availability, including more competition from similar products (for example, to reduce price) and registration of miltefosine and other VL drugs in more East African endemic countries, which otherwise cannot import them.

Rachel ter Horst is a Dutch physician who has worked for Médecins sans Frontières since 2003. She is currently serving as medical advocacy advisor, based in Amsterdam.

1. Ritmeijer K, Veeken H, Melaku et al. Ethiopian visceral leishmaniasis: generic and proprietary sodium stibogluconate are equivalent; HIV co-infected patients have a poor outcome. Trans R Soc Trop Med, 2001, 95;668-72.

2. Ritmeijer K, Dejenie A, Assefa Y, et al. A comparison of Miltefosine and Sodium Stibogluconate for treatment of Visceral Leishmaniasis in an Ethiopian population with high HIV-prevalence. Clin Infec Dis, 2006, 43 (3): 357-64.

3. Ritmeijer K, ter Horst R, Chane S, et al. Limited effectiveness of high-dose liposomal amphotericin B (AmBisome®) for treatment of visceral leishmaniasis in an Ethiopian population with high HIV prevalence. Clin Infect Dis 2011: Dec;53(12):e152-8. Epub 2011 Oct 19.

4. Drugs for Neglected Diseases initiative (DNDi), Gondar University, Ethiopia, and the Institute of Tropical Medicine (ITM) in Antwerp, Belgium.

5. Ter Horst R, Collin S, Ritmeijer K, et al. Concordant HIV infection and visceral leishmaniasis in Ethiopia: the influence of antiretroviral treatment and other factors on outcome. Clin Infect Dis 2008:46;1702-9.

On the menu: progress towards elimination of one of the world’s most neglected tropical diseases, sleeping sickness (human African trypanosomiasis [HAT]). Sleeping sickness is a parasitic disease transmitted by the bite of an infected tsetse fly. The disease affects mostly poor populations living in remote rural areas of Africa. If left untreated, HAT is usually fatal.

Elimination of the disease implies a reduction in incidence to zero in a defined area (as opposed to eradication, which is a permanent reduction to zero of worldwide incidence, after which intervention measures are no longer needed). Continued intervention measures are required to prevent re-establishment of transmission.

Over the past 10 years, considerable progress has been made in the control of sleeping sickness. In several countries, no cases have been diagnosed for over a decade. In others, especially the Democratic Republic of Congo (with nearly 7200 reported cases in 2009 and over 5600 in 2010; 80% of all reported HAT cases), the Central African Republic, South Sudan, Uganda and Chad, the annual reported incidence is considerable. However, the real incidence in these countries is not actually known, because some HAT endemic areas are too insecure to access, lack health care and surveillance, or both.

Médecins Sans Frontières (MSF) has been involved in sleeping sickness treatment since 1986. The organisation tends to go where the disease burden is highest, and national control programme teams or other non-governmental organisations do not go because of war, insecurity, or lack of capacity. While implementing extensive active case-finding and providing life-saving treatment, MSF advocates enhanced coordinated efforts and research and development into better diagnostic tests and treatments. The current diagnostic test (card agglutination test for trypanosomiasis followed by cerebrospinal fluid microscopy for confirmation and staging) and treatment tools (pentamidine intramuscular injections for stage 1, NECT [nifurtimox-eflornithine combination therapy; includes twice daily eflornithine intravenously for a week] for stage 2) require trained medical and laboratory staff, and are difficult to integrate into primary health care (where available).

The new MSF international mobile HAT team was introduced at the conference. Operating in countries with highest burden of HAT, the teams will facilitate diagnosis and treatment for neglected populations that are difficult to access, investigate suspected transmission areas, strengthen surveillance capacity, raise awareness and action at national and international levels, and assess and integrate new approaches.

Good news on sleeping sickness diagnostics came from the Foundation for Innovative New Diagnostics (FIND), who presented their diagnostic pipeline. If all goes well, by late 2012 there could be a rapid diagnostic test for sleeping sickness. A lumbar puncture will still be needed to establish the disease stage of a patient since this determines the choice of current treatments. Research is ongoing into developing a biomarker (neopterin) test that can be performed on blood. If that becomes successful, it would greatly improve feasibility of scale-up and integration of HAT care into the health system.

On the treatment front, a hopeful compound in the pipeline of the Drugs for Neglected Diseases initiative (DNDi), named fexinidazole, was discussed. Clinical trials with patients are planned for early next year. Fexinidazole, a once-daily tablet, will hopefully work for both stages of the disease. Another drug candidate is an oxaborole currently named SCYX7158. The outlook is encouraging, but it is still early days.

Trypanosomiasis not only affects humans, but also livestock such as cattle. Animal trypanosomiasis is called Nagana, a Zulu word meaning “to be depressed”. Since the disease affects livestock, economic implications and the attention of many more actors is coming to the fore. Land cleared of the tsetse fly can be turned into agricultural or grazing land. Tourists in national parks should not be infected. Huge investments are being made into preventing animal trypanosomiasis, such as cattle spraying, cattle foot baths, insecticide-treated fencing, and vector control such as aerial spraying and releasing sterile male tsetse flies.

My mind drifts back to the human disease, with its human implications, and an inspiring message that has started shining through the darkness. Numbers of sleeping sickness cases are steadily decreasing through
coordinated efforts. Elimination of this scourge from even the hardest-to-reach places could become feasible. A good rapid test, effective treatment in tablet form, commitment, action (including surveillance), and investment are the ingredients needed to push sleeping sickness down and keep it down.

This is a guest blog written by Rachel ter Horst, the Medical Advocacy Adviser at Médecins Sans Frontières (MSF)

Also posted on the BMJ blog: http://blogs.bmj.com/bmj/2011/09/29/rachel-ter-horst-inspiring-progress-in-the-fight-against-sleeping-sickness/

One pressing problem with treating infant HIV infection is that the drugs might work, but they aren’t tailored for the specific needs of infants: a typical regime for a newborn is 3 different syrups (one for each drug), given in three different doses (with dosage dependent on weight). As if this isn’t difficult enough for caregivers to administer, the drugs taste vile and need refrigeration — hardly ideal for child or indeed mother. Recognising the need for new formulations, DnDi yesterday launched a new initiative for an R&D agenda to develope pediatric formulations of antiretrovirals. According to Shing Chang, Director of R&D at DNDi, the goal is a fixed dose combination treatment to treat HIV and HIV/TB coinfection in infants under 3.

DNDi might seem an unusual partner for drugs that are needed by so many, but Marc Lallemant, Head of the HIV Programme at DNDi, noted that ‘children living with HIV/AIDS are a neglected population and pediatric AIDS can be considered a neglected disease’. Certainly it would seem Pharma are neglecting this in-need group, perhaps because the introduction of treatment for mothers means the number of babies born infected with HIV represents a shrinking market.

I spoke to Rachel Cohen, Regional Executvie Director for DNDi, North America, and asked whether there was any attempt to link care of infants to PMTCT programs, and she agreed this would be ideal. But sadly, access to PMTCT and uptake of PMTCT services still needs massively improving, and linkage to care of both mothers and children is far less than ideal.

As Dr. Musoke concluded, we must continue to improve maternal and child health through scale-up of PMTCT programmes, strengthening integrated approaches to maternal and child health (including HIV care) and providing integrated family planning services.

If you asked the average American if they’ve ever heard of sleeping sickness, river blindness, or elephantiasis, you’d likely get a puzzled look. But ask a Congolese, Sudanese, or Bangladeshi about these parasitic diseases, and you might get a nod of the head or perhaps even a point in the direction of someone behaving erratically and slipping into a coma due to sleeping sickness, being led by stick by a child because of river blindness, or barely able to walk due to grossly swollen legs or genitalia caused by elephantiasis.

This weekend in Boston, health workers, researchers, donors, and social innovators from around the world will convene to discuss current efforts to treat patients and develop new drugs and vaccines for neglected tropical diseases (NTDs) such as these. Most of us have never heard of these diseases, although they are the most common infections of the world’s poor, debilitating or killing more than 1 billion people in the developing world.

This first-ever NTD meeting of the International Society for Infectious Diseases offers an opportunity for U.S. policy-makers and the public to better understand the devastating toll these illnesses exact on the world’s poorest and most vulnerable people. It may also shine light on the commendable achievements — as well as some limitations — of the current approach the U.S. government is taking to tackling NTDs.

The elimination of certain NTDs has been set as a goal by the U.S. Global Health Initiative (GHI) and World Health Organization (WHO). Great progress in reaching these elimination targets is being achieved through a program of mass treatment. To date, more than 100 million people have received access to essential medicines for NTDs thorough funding from the U.S. Agency for International Development (USAID).

However, for many NTDs, elimination will not be possible using existing drugs because they are limited in effectiveness and safety, are difficult to use, or come with serious concerns about resistance. Therefore, while continuing to provide existing medicines for NTDs, there is an urgent need to implement a parallel program of development, manufacture, and clinical testing of new drugs, diagnostics, and vaccines.

While basic research and early-stage product development is supported by the National Institutes of Health and should continue to be funded at ever-increasing levels, late-stage product development, including for drugs, diagnostics, and vaccines, is urgently needed to bring new health technologies through the “pipeline” to patients. This would help bridge the gap between innovation and access and would align NTDs with other USAID programs in malaria, HIV/AIDS, and tuberculosis, which currently allocate a percentage of their funding for late-stage product development.

Neglected disease researchers are trying to do their part. At the ISID-NTD meeting in Boston, the Drugs for Neglected Diseases initiative (DNDi), a non-profit R&D organization focused on sleeping sickness, Chagas disease, and leishmaniases, will announce the start of a new project testing the drug flubendazole in people suffering from either river blindness or elephantiasis. If effective, this drug could dramatically improve case management and simplify mass drug treatment of patients throughout Africa and Asia. The Sabin Vaccine Institute will describe new vaccines in development for hookworm, schistosomiasis, and Chagas disease, one of which will soon enter clinical trials.

Up to 600 million people are infected with hookworm and schistosomiasis, and 120 million with elephantiasis throughout the low- and middle-income countries of Africa, Asia, and Latin America, Another 26 million have river blindness, while up to 10 million people have Chagas disease, a leading cause of heart disease in Latin America.

The U.S. has led the way in ensuring the poorest people receive urgently needed treatments for NTDs, while simultaneously supporting programs of basic research. This commitment has spanned several presidential administrations, receiving widespread support from both Democrats and Republicans in the U.S. Congress. This weekend, we will join with other leading NTD experts in Boston to call for the expansion of the U.S. government’s approach to NTDs so that it includes new investments in R&D to develop and test new products for a wider range of neglected diseases. Only then will we be able to eliminate the neglect of millions of poor people in need and at risk.

Bernard Pecoul, MD, MPH is Executive Director of the Drugs for Neglected Diseases initiative, and Peter Hotez, MD, PhD is President of Sabin Vaccine Institute at Texas Children’s Hospital and Baylor College of Medicine, and Editor-in-Chief of PLoS Neglected Tropical Diseases

Source: Map created by Jessica Schwartz, The George Washington University doi:10.1371/journal.pntd.0000843.g001

Outside of the US, Washington, D.C. and the Gulf Coast are, respectively, more likely to be thought of as the seat of global power or as the home of endless sunshine. By contrast, Hotez argues that “Hurricanes Katrina and Rita and the BP oil disaster have shed light on a tragic level of poverty in the northern Gulf of Mexico” and that “Washington, D.C., rivals Louisiana, Mississippi, and Alabama as among the worst in terms of life expectancy and health index”. His list of the diseases common in these communities is stark, and shaming -Trichomoniasis, Toxocariasis, congential toxoplasmosis and cytomegalovirus – even leaving aside the “astonishing” prevalence of HIV- 6.5% of African American males in Washington, D.C..

His conclusion is hard to disagree with: “The fact that we know so little about the neglected infections of poverty in America’s most distressed areas is representative of just how glaring these conditions are as health disparities.”

“It never ceases to amaze me how much Medsinners [members of Medsin] accomplish while studying full time, and with such limited resources; giving up weekends and evening to work for the cause,” says Elly Pilavachi, the current national co-ordinator of Medsin , a student led UK charity. And the cause? Medsin’s mission: “to create a network of students, empowered to effect tangible, social, and political change in health on a local, national and global level through education, advocacy, and community action.”

I wholeheartedly agree with her words and share her amazement. Medsinners are awesome as I witnessed last weekend while at Medsin’s national global health conference based in Cambridge. In addition to the logistical triumph of the Cambridge student team in organising such a huge conference (there were 4 plenary sessions with 3 speakers in each and up to 60 workshops), over 300 students (the majority of which were medical students) from around the UK, gave their time, energy, and scare financial resources to learn more about the conference theme: “The mad and the bad: the diseases that nobody talks about.”

Many diseases and conditions could fall into this area but the conference focused particularly on the neglected tropical diseases and mental illness. At first glance, these two areas may not appear linked but there are many overlapping issues. For example, people with neglected tropical diseases, such as leprosy, and people with mental health problems are stigmatised by society. One of my most memorable memories of the conference is the talk given by Peter Byrne, a consultant liaison psychiatrist and Director of Education for the Royal College of Psychiatrists, who eloquently demonstrated how people with mental illness continue to be stigmatised in the way in which they are portrayed in film and the media.

Plenary sessions and workshops discussed the particular issues of neglected tropical diseases, such as the lack of affordable treatments and diagnostic tests, mostly due to the lack of pharmaceutical company involvement in the Research and Development of this unprofitable market area. But there are many possible solutions to help move forward, including public private partnerships and publications such as PLoS Neglected Tropical diseases. Others looked at WHO’s Global Burden of Diseases and how in 2030, there will be no infectious diseases in the top 15 conditions — chronic non communicable diseases and road traffic accidents will lead the way. Articulate student advocates for Pharmaware, Universities Allied for Essential Medicines and minds for health enlivened many sessions.

At the end of an exhausting weekend, I felt that the conference and its passionate participants had not only exemplified Medsin’s mission but also its Vision—a fair and just world, in which equity and health is a reality for all. If doctors of the future are anything like these marvellous Medsinners, there is hope for the world, a realistic opportunity to improve global health and the chance to make a lasting difference.

As I began with the words of Elly Pilavachi, I will also finish with them: “On these occasions when we are left feeling bereft of energy, when our work appears to go unrecognised, and we struggle to grasp the results, there is nothing more invigorating than knowing that there are thousands of young people in the UK who are still striving for the same outcome.” Amen to that!

Competing interest: RM is a Trustee of Medsin