Bordering on the Elimination of NTDs
October 28, 2015
Working together to expand pharmaceutical research agendas, improve the access of vulnerable populations to quality health care, and encourage decision-makers to tackle tough social problems, the United States and Mexico have an opportunity to eliminate the shared challenge of neglected tropical diseases (NTDs), according to experts at a September 30 workshop held at Rice University's Baker Institute for Public Policy in Houston, Texas.
Across several keynote addresses, as well as during panel discussions, speakers representing academic institutions, private foundations, and government agencies agreed that the new Sustainable Development Goal target to "end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases by 2030," which is embedded within Goal 3 ("Ensure healthy lives and well-being for all at all ages"), creates an excellent opportunity for building the political will to eliminate the transmission of NTDs in the United States and Mexico.
The phrase "neglected tropical diseases" (NTDs) was introduced in 2005 to describe a group of some 17 parasitic, bacterial, and viral diseases, including dengue fever, Chagas disease, onchocerciasis (river blindness) and helminth infections, which are commonly reported in tropical and sub-tropical areas. Associated with poverty, low access to quality health services, and poorly managed environmental conditions, NTDs may cause disfigurement, blindness and pain, as well as neurodegenerative disease and cardiac irregularities. NTDs can be difficult and time-consuming to diagnose in regions where health care providers are not accustomed to seeing them, and they can lead to death, as well. Their concentration among the poorest social sectors and infrequent presentation often make them invisible to policymakers, but their human and economic toll is significant.
Worldwide, more than one billion people, the majority of whom are children, are infected with an NTD. Nearly 500,000 people die from NTD infection each year.
Despite differences in the structure of each country's health system and annual health care spending per capita, the United States and Mexico share a common challenge in eliminating NTDs. In the United States, an estimated 12 million Americans living in poverty are infected with an NTD. Thanks to long-term, multi-sectoral public efforts, Mexico has reported recent progress in controlling rabies, leprosy, and malaria and in eliminating onchocerciasis, according to Secretary of Health Mercedes Juan López, who spoke at the session. However, challenges remain. Women and children, people living in rural areas, and those living in indigenous communities in Mexico are more likely to be exposed to NTD infection because of their greater rates of poverty. The poorer southern regions of both countries report the highest rates of NTDs, and the U.S.-Mexico border region, considered to be the 60 miles on either side of the nearly 2,000 mile border, is home to roughly 15 million people who also experience high rates of poverty and exposure to NTDs.
Speakers at the meeting focused attention on NTDs' economic impacts, with several emphasizing that the relationship between NTD infection and poverty is a "closed loop," in which the poorest populations are disproportionately exposed to NTDs, and NTD infection can reinforce and deepen poverty. Chagas disease, which is caused by the parasite Trypanosoma cruzi and is transmitted through insect bites, is reported only in the Americas, with an estimated 9.4 million people infected. The cardiac complications associated with the parasitic infection cost an estimated US$7.2 billion globally and US$864 million in the United States alone, according to Peter Hotez, Dean of the Baylor College of Medicine's National School of Tropical Medicine, which co-hosted the event.
Speaking about the connections between disease and poverty in Mexico, Roberto Tapia-Conyer, Director General of the Carlos Slim Foundation, noted that there is a strong association between ill health and poverty in Mexico's least economically developed states. The principal risk factors for disease in children under the age of five include malnutrition, poor sanitation, low levels of hygiene, and low access to clean water. He also stated that at least 20 million people in Mexico suffer from helminth infections and estimated that chronic hookworm infection in childhood reduces future wage earnings by 40% or more.
Dengue fever, which is transmitted by the mosquitoes of the Aedes aegypti species, is a challenge on both sides of the border. In Houston's 5th ward, one of the most impoverished areas of the city, health officials have documented cases of local dengue transmission thanks to poor vector control, few air conditioners or screens on windows, and water stagnating in old tires or piles of uncollected trash left in the streets. In Mexico, dengue infections, which are reported across the country, are estimated to cost between US$138 million and US$328 million each year. Mexico must continue to improve its dengue surveillance, train health workers to diagnose and treat dengue, and enhance vector control and water resource management programs to reduce the proliferation of the mosquitoes that transmit dengue, along with the newer Chikungunya virus, which was introduced into the Americas in late 2013 and reported to have begun transmitting locally in Mexico as of October 2014.
Strengthening partnerships between the public, non-profit, and private sectors can accelerate progress on developing vaccines, rapid point-of-care diagnostic kits, and treatments for many NTDs, but convincing policymakers to invest greater resources in surveillance, training, and services to address NTDs has been a challenge. United States overseas development assistance programs focused on NTDs rose from an initial US$15 million in 2006 to US$100 million in FY2014 and 2015, but speakers at the session agreed that scientists and advocates must do a better job of collaborating and "humanizing" the NTD challenge so that it resonates for decision-makers in both countries. Most U.S. funds for work on NTDs support programs in sub-Saharan Africa and Asia; Haiti is the only country in the Americas receiving U.S. support to address NTDs.
There are several mechanisms that could facilitate U.S.-Mexico cooperation on NTDs:
In May of 2012 the United States Department of Health and Human Services and the Secretariat of Health in Mexico formalized a set of "Guidelines for Cooperation on Public Health Events of Mutual Interest." While the guidelines are focused on the movement of people between the two countries and do not refer explicitly to NTDs, they leave open the possibility of cooperating on a broad range of health challenges, which could include NTDs. The two governments could also use the Binational Technical Work Group, which in the past has facilitated inter-governmental cooperation on public health priorities, to develop a plan for cross-border cooperation on NTD challenges.
The bi-national United States-México Border Health Commission, which is based in El Paso, Texas, engages federal and state authorities, as well as community health leaders, in both countries in promoting research and outreach to "optimize health and quality of life along the U.S.-Mexico border." It could also be used to advance bilateral cooperation on NTDs. Chronic and degenerative diseases, as well as infectious diseases, are already strategic priorities of the BHC. The Commission could strengthen its focus on immunizations and its partnership with local providers and advocacy organizations to raise awareness about NTDs among border area decision-makers and residents.
The Salud Mesoamérica Initiative, which is managed by the Inter-American Development Bank and supported by the Carlos Slim Foundation, the Bill and Melinda Gates Foundation, and the Government of Spain, along with the governments of Mexico and the Central American countries, can also focus greater attention on the NTD challenge in southern Mexico and in the neighboring countries. Described as "an innovative public/private partnership to reduce health equity gaps in Mesoamerica," the initiative already focuses on reproductive, maternal, neonatal and child survival and could incorporate a focus on NTDs into its work on child health in the region.
The new SDGs place a high priority on equity and ensuring that the poorest of the poor are effectively incorporated into development processes. With this ideal in mind, the United States and Mexico can prioritize research, policy, and program activities to eliminate NTDs and ensure the access of the most vulnerable citizens on both sides of the border to quality health services. The lives and well-being of millions in both countries are at stake.