So, very important progress has been made against a number of the neglected tropical diseases, including the seven we've been discussing. In addition, getting worms is on the verge of being eradicated. For insightful comments about how neglected tropical diseases can be addressed, and the challenges of doing so, let's turn now to Dr. Peter Hotez. Dr. Hotez is the Dean of the National School of Medicine at the Baylor College of Medicine in Houston, Texas in the United States. Among other things, Dr. Hotez is one of the leading authorities in the world on the neglected tropical diseases. And a pioneer in getting the neglected tropical diseases to be less neglected than they were before. Peter and I are very old friends, and so I'm going to take the liberty of calling him Peter, and he'll be calling me Richard. Peter, I can't thank you enough for joining us today. I'm extraordinarily grateful that you would take the time to do so, given the many hats you wear and the many activities in which you are engaged. So, what I'd like to do with your kind permission is get some thoughts from you about the progress against these diseases, and the challenges of further addressing them. I'd like to begin by asking you if you could comment on some of the progress in the last decade or so in addressing these NTDs. >> Well, Richard, thank you so much for inviting me to participate in your very important initiative, it's always and honor to be working with you. Back in, after the launch of the Millennium Development Goals when they called our diseases other diseases we recognized. That calling something quote and quote other diseases was not going to be very powerful on some advocacy in terms of getting people very excited about the most common chronic afflictions of humankind. So we branded them as NTDs or neglected tropical diseases right certainly afterwards. And then, began to notice that for a subset of them, as you mentioned, seven of them, meaning the three intestinal worm infections, ascariasis, trichuriasis, and hookworm and lymphatic filaria. As well as lymphatic filariasis, river blindness, schistosomiasis and trachoma there was an opportunity to bundle interventions against those seven diseases. So we published, in 2005, in the Public Library of Science and plus, this concept of a rapid impact packaging. Package of medicines that were mostly being donated by the big pharmaceutical companies, and then therefore could be administered free of charge. So we put together this concept of a package published it in 2005, and worked very hard with the, I worked very hard with the US Congress. My colleagues David Mulleneaux and Alan Fennick worked very hard with the UK Parliament, and we were able to get funds appropriated fairly quickly in a record time, I think. From the time we went from publishing a paper to to policy and then translating it into providing overseas development assistance. We began to see funding come through for administration of the package and we've made a lot of progress over the last decade. So it began modestly with $15 million appropriated through the United States agency for international development in 2006 and now we're up to about $100 million a year. Now as overseas development assistance goes that's not necessarily big dollars compared to the $8 billion spent annually on the President's Emergency Plan for AIDS Relief,PEPFAR. But we can go a long way with our package because we can do this for $0.50 a person per year. And what we've seen so far, is that now according to my colleagues that USAID, more than 450 million people have been treated with at least one of the essential medicines involved in the rapid-impact package. So the question now and I guess that's a long preamble to really directly answer to your question, what's been the impact? Well, I know you're very familiar with the global burden of disease study which is housed at the Institute for Health Metrics and Evaluation in Seattle. We've not been working very closely with them on the neglected tropical disease component, the NTD component that rapid impact package and there are some impressive numbers. So what we have seen according to our efforts working with University of Washington in Seattle. Is that we've seen up to a 40% reduction in the global prevalence of three neglected tropical diseases that are targeted by that rapid impact package. We've seen massive reductions in lymphatic filariasis sometimes also known as elephantiasis. Similarly, massive improvements in the reductions and prevalence of river blindness and finally trachoma. So this has been, in my opinion, a spectacular global health victory. One that could be put on rank with other great achievements such as childhood vaccines and others. Having said that, we've also noted that two of the diseases targeted for the rapid impact package, schistosomiasis and hookworm, we have not seen the kinds of gains we had hoped for. We can talk about why we have seen so much improvement in LF, lymphatic filariasis, river blindness, and trachoma but not so much schistosomiasis and hookworm defection. >> Thank you very much. Of course, countries themselves must be in the lead in efforts to address these neglected tropical diseases. And I wonder if you could comment a little more on the kind of collaborations internationally. And within countries, that are allowing this work to be done in many places, so effectively and so inexpensively as well. >> Well, that's a great question Richard and one of the exciting things about administering this rapid impact package is it is empowering for the disease ridden countries. Because what we have seen is that the ministries of health and the collaborators can take on a lot of ownership. So the package was designed so that it could be administered once or twice a year. The bias safety profile of the drugs is very high, it's a unnecessarily complicated way of saying the drugs are very safe. As a result, they do not have to administered by a healthcare professional. They can be administered by a school teacher or a community health worker. And so, it's relatively easy to have access to people living in poverty by working through school teachers and community health workers. And that's why we've been so successful widely distributed these medicines. That's point one, and point two, is because it's only once or twice a year that that's helpful. And also because it's so low cost that the ministries of health can take a lot of ownership. In some cases we've seen, for instance, in places such as Burkina Faso they take on, which is one of the poorest countries on Earth. They've taken a lot of ownership on, they actually are paying for us some of these deliveries because it's only $0.50 a person per year. It's not overwhelming the health system. So and then what we've seen and this is some exciting work done by Frank Richards at the Carter Center And others is that the administration of the rapid impact package has provided a platform to which to add on other interventions. So Frank Richardson McCarter Center and his colleagues were the first to show that if you provide anti-malarial bed nets to people administering the rapid impact package, the use of bed nets can go up seven fold. But the sky is the limit. We think it's the allegory of stone soup, where a child puts a stone in a bowl and puts some water in it, and somebody says well, you can't make a soup out of that. You need to add the carrots and the other vegetables. And before you know it, you have a very rich broth. Well, it's very much like that with the rapid impact package. That's just the beginning because now you could add on anti-malarial bed nets. You could provide micronutrients, you could provide childhood vaccines. So we're hopeful and optimistic that this rapid impact package itself could be health systems strengthening, especially in the world's poorest countries. >> And Peter, if I may, I just wanted to clarify, I know at one time, I thought that all but one of the drugs were being donated by pharmaceutical firms. But am I right in understanding that at this time, all of the most important drugs for the rapid impact package are being donated as part of an international collaboration? >> Yes, that's correct. So what happened was we wrote the original papers on the rapid impact package back in 2005. And we immediately had pharmaceutical cooperation from the multinational pharmaceutical companies. What then happened was the Gates Foundation, the World Health Organization were very instrumental in 2012 in creating what was called the London Declaration for neglected tropical diseases that got the big pharmaceutical companies to redouble their commitment for NTDs and bring in some new actors. So now we're in a situation where we have GlaxoSmithKline donating the albendazole, Johnson and Johnson, J and J, donating the mebendazole. We have the German Merck, sometimes called Merck KGaA, or just plain Merck, donating the praziquantel. You have an American company, based in the US, providing the afromectin, Eisai, the Japanese company, is donating diethylcarbamazine citrate, Pfizer, the Zithromax. So this is very much a good news story. And it's not a trivial contribution from the pharmaceutical companies. Any time you're donating a billion of anything, that's real work to scale that up at that level. >> Peter, I wonder if you could look forward a bit to the next decade and talk about what you think will be the most important challenges over this period in further reducing the burden of NTDs. So one of the things that we're hoping for is that we'll be able to maintain the commitment. Right now, there's enormous amount of pressure on the US and UK governments to provide the support for the rapid impact package. I think a clear trend is we want to see this continue, we're going to need participation by some of the other European countries. We also think that the G20 countries that are outside of Europe and the US could make major contributions, the BRICs countries, Brazil, Russia, India, China. And we'll talk a little bit more about the G20 in a moment. So, I think one of the trends that we hope to see is that this continues, and if so, one of the hopes is that we'll see the elimination of at least two diseases, meaning elephantiasis and trachoma. Because they're interrupting transmission of these diseases over the next few years, maybe as early as 2020. That would be a very powerful thing to have happen. We're also going to see big gains in river blindness, although there's some question of whether we're going to need new technologies, such as a river blindness vaccine we're working on. The big problem from my perspective has been hookworm and schistosomiasis. And there is not consensus in the global health community about what's going to happen. There are people who are very convinced that the power of mass drug administration and believe that through some tweaks that we could eliminate hookworm or schistosomiasis. If we change, it'll vary our practices and step up our coverage rates. I have a different perspective. I think we're going to need new technologies, and for that reason, my laboratory, which is the Sabine Vaccine Institute, which is a nonprofit product development partnership that develops new technologies for neglected tropical diseases, was actually developing first generation hookworm and schistosomiasis vaccines. And these are now in phase one clinical trials in Gabon, in Sub-Saharan Africa and Brazil. The idea being that if we were successful in the product and clinical development of these vaccines, we could eventually fold them into the mass drug administration package. So that's where I think the progress is going to go with the diseases targeted by the rapid impact package. But we're seeing some alarming new trends for neglected tropical diseases, which I think are worth talking about. One of the things that we've seen for the neglected tropical diseases now as they're defined by the World Health Organization, we had our original list of 13 or 14. WHO has expanded that to 17, and I think it's a very good list, is we've seen some dramatic increases in selected neglected tropical diseases outside of those that are targeted by the rapid impact package. Particularly some of the vector borne neglected tropical diseases, neglected tropical diseases transmitted by insects, or in some cases, snails. So we've seen, for instance, an explosion in the number of cases of arbovirus infections, the best known one being, of course, dengue. And we've seen a massive increase in the global burden of dengue. And it's not just dengue, we've seen other viruses transmitted by mosquitos, such as chikungunya, and of course, Zika virus, really take off. We've seen massive increases in leishmaniasis, which is transmitted by sand flies. So we're trying to get our arms around what's happening there. And we know that there's been a number of new forces in play, certainly climate change, we think, is an important factor. Poverty's an important factor. Human migrations are an important factor. But this is one of the big unanswered questions in our field, what is it that's causing this global acceleration of some of the vector-borne diseases? Let me give you a very striking example of something that would not be intuitive. In Southern Europe over the last few years, we've seen the reemergence of malaria in Greece. We've seen chikungunya, West Nile virus infection, and dengue in Portugal and throughout Italy, southern Spain, southern France. We've seen schistosomiasis in the island of Corsica, if you could believe that, off the coast of France. And so, something very odd is going on. I've even, in an article I wrote for Vice Magazine, I made a comparison to what we're seeing in southern Europe. With the early sequences of the 1980s Ghostbusters movies. Where you saw the green blob on the table in the hotel and we saw the skeleton in the taxi cab and you knew something really bad was about to happen, but you couldn't quite connect the dots. And that's what we're seeing in southern Europe. Part of it may be a spillover from the conflict in the Middle East. We know that next to poverty, conflict is one of the most important drivers of MTDs. That's why Ebola virus emerged in West Africa, because Guinea, Liberia, and Sierra Leone were decimated by the healthcare infrastructure. There we're seeing the same knot in the ISIS occupied territories and Syria and Iraq and Libya. So we're really trying to understand now what it is that's accounting for this terrible rise in vector borne disease. So that's going to be a major challenge for instance. >> Peter, let me ask you to help me bring this session to an end. By saying if you had just two or three minutes to speak to the World Health Assembly for example, in a session on Neglected Tropical Diseases, what are the two or three most important messages that you would want the Ministries of Health throughout the world to understand about NTDs? Well Richard I've seen you teach many times and I've seen you ask that question to your students. And I was really hoping you would ask me that, and you did and so I'm thrilled. Well- >> It's out of deep respect, Professor Hortez, that I do that. Well now I am going to tell you. So I've just finished a new book and the name of the book is Blue Marble Health, to give it a different name than Global Health. And it has to do with this, when it comes to neglected tropical diseases, the biggest driver of all is poverty. NTDs both occur in the setting of poverty and they reinforce poverty because of their long term impact on child development, on pregnancy, on worker productivity. So we've done a deep dive down after the 15 years of the millennium development goal, what's our current status of the world's Neglected Tropical Diseases? We found something that for me was counterintuitive, and that is most of the world's Neglected Tropical Diseases are no longer in necessarily and the most devastated countries and places, like Sub-Saharan Africa and. Yes, they're in Central African Republic, in Congo, in Somalia. But what we're finding is that most of the worst neglected disease are actually in the 20 wealthiest economy, the G20 countries, together with Nigeria. But it's the poor living among the wealthy that are accounting for these. So if you look at the G20 countries, they now today, together with Nigeria count for at least half of the world's element infections, such as as the ones we have been talking about, lymphatic filariasis, intestinal worms. They account for most of the dengue, most of the tuberculosis, most of the leishmaniasis, most of the Chagas disease, most of the leprosy, and others. And that's a very important observation, because it says that in many cases, it's not a resource problem, it's a political will problem. So if we could get the G20 leaders together and make them commit to their own vulnerable populations, whether it's in Western China, where we find high rates of infections not in Shanghai and Beijing, but in Sichuan, Yuunan and Guizhou provinces. Or if you go into northern Argentina, up in the Chaco. Or if you go into northeastern Brazil, which Brazil is the wealthiest economy in Latin America. Northeastern Brazil is ground zero for NTDs where you have not only Zika but also elephantitis. And schistosomiasis in southern Mexico or even the southern United States. We're finding that there are 12 million Americans now living with a Neglected Tropical Disease, such as Chagas disease. Such as cysticercosis, such as toxichoriasis. If we could get those G20 leaders to commit to their own vulnerable populations, we could wipe out two-thirds of the world's neglected diseases in a very short period. So if I had the opportunity to address the G20 health ministers, I would ask the health ministers of the G20 countries to raise their hand, and I would bring them into a little side room. And I would shake my finger and say, if you could convince your leaders to take on the NTD's in your own countries, we can go a long way to solve the problems. >> Peter, I can't thank you enough. You have many, many things to do. And I'm extremely grateful that you would take time from your very busy and very impactful schedule to join us for this session. It's been an honor and a pleasure as always to see you, an old and dear friend. And I thank you as well for all of the wonderful work you're doing in addressing the NTDs, as well as in other areas of global health. And how you're modeling it for my students and for many people elsewhere, the kinds of work we hope more and more people will attend to as well. So thank you very much and I look forward to keeping in touch soon.
