By John Donnelly

Dr. Peter J. Hotez is professor of Pediatrics and Molecular Virology and Microbiology at Baylor College of Medicine and is chief of a new Section of Pediatric Tropical Medicine and founding Dean of the National School of Tropical Medicine. He also is President of the ASTMH, and on Wednesday night he delivered a call to move toward the elimination of all neglected tropical diseases by 2020. Hotez talked in an interview about what needs to happen next. 

Q: Why issue this call?

A: There are 17 major neglected tropical diseases. To take on this audacious goal, which follows the Bill & Melinda Gates Foundation’s goal to eradicate malaria, is saying in essence that we need to be on a faster track to get rid of these tropical diseases. We need to be talking about a bold vision.

Q: What will be some of the strategy behind this vision?

A: One is we have to scale up the mass drug administration approaches, as supported by USAID, DFID, as well as through our own END Neglected Diseases initiative, which we announced Monday night. We need to scale up the distribution of drugs and other items such as distribution of bed nets, but we also need to invest in parallel research and development to eliminate these 17 neglected diseases. We need to do both together. So much of the argument has been focused on either or, one or the other.

The point is there has not been adequate funding. The research has only picked up since 2000, when the Bill & Melinda Gates Foundation started funding Product Development Partnerships, or PDPs, which helped non-profits start to use industry practice. Now we need to get the US and European governments supporting these PDPs. And it’s equally important not to just rely on the US and Europe governments. We need to think about emerging economies. Brazil, China, India, Indonesia, Thailand, and all the sovereign wealth of the Middle East – we need help from all of them. 

Q: Of the 17 neglected diseases, which ones are the most promising candidates for elimination?

A: Leishmaniasis is one, especially with the elimination initiatives in South Asia, and the development of new medicines at the same time. There’s also guinea worm, trachoma, onchocerciasis, and leprosy. 

Q: This obviously is a difficult task, but what do you see as especially hard to do?

A: We need better coordination and we need more funding. We need new actors to help out, high-net worth individuals in places like Brazil, China, India. You can’t rely only on the governments who have been giving; we also need new governments. The Bill & Melinda Gates Foundation is just the beginning. We’re starting to see now others, such as the Carlos Slim Institute.

We’ve got to expand the base. The US government has not been supporting PDPs that much. They support a lot of basic research, the president’s GHI initiative, but just 1 to 2 percent of that is going to fight neglected tropical diseases.

By John Donnelly

All Dr. Paul Farmer wants is equity.

He wants the people of Haiti, the people of Rwanda, the people in developing countries everywhere to have the same access to good health care as anyone else in the world.

And he doesn’t understand why anyone would disagree.

Farmer delivered the keynote lecture Tuesday at the ASTMH annual conference in Philadelphia, telling a packed convention hall that the situation in Haiti post-earthquake shows how a poor health system, fueled by dirty water supplies everywhere, created conditions for the world’s worst outbreak of cholera.

Farmer – well-known in global health circles for his nearly three decades of work in Haiti and elsewhere around the world and for the depiction of him in Tracy Kidder’s Mountains Beyond Mountains, required reading for many college freshmen – said that cholera could spike again during the next rainy season. In fact, he saw no reason why it wouldn’t, as Haiti’s chronic health and infrastructure problems are nowhere near fixed.

“If we do not invest in municipal water systems, there will be major outbreaks of water borne disease,” he said. He said that “cynical manipulation of foreign aid” derailed water projects in 2002 and 2003, and “now it will take years to rebuild that system. How long does it take to build public water systems with governments? It takes a long time. We don’t have a long time.”

He called on scientists, researchers, physicians, and students belonging to the Society not to shy away from a health “equity” agenda for Haitians and for poor people around the world. “Call it equity strategies,” he said, adding that “understanding the role of equity is one of the major challenges in 21st century research.”

One place in great need of more people fighting for equitable treatment is Haiti, he said.

“The standard of care has to be of the highest caliber in Haiti because this is one of those clear examples of international responsibility of what became in 300 days the largest killer of adults in Haiti’’ – the cholera epidemic, which has killed more than 7,000 and has hospitalized more than a half-million people. The outbreak came just 10 months after a devastating earthquake ruptured Haiti, killing an estimated 250,000 people and leaving more than 1.3 million people homeless.

“I hope some of you share the sense that I have -- I am appalled such a small country, Haiti, with 10 million people, could be home to such a huge epidemic (of cholera),” he said. “It would have been much worse without the humanitarian aid, but this is still completely unacceptable, as long as we have an equity strategy.”

Farmer also echoed the calls of ASTMH’s leadership for Society members to become more effective advocates in pushing forward the agenda of global health in order to bring better health care to all.

“Think of the impact we can have when we link our understanding of improvements in people’s lives to policy endeavors that can change the lives of millions,” he said. “There’s a problem why it doesn’t happen more in our world of tropical medicine and neglected tropical diseases. All of our diseases can be defined as neglected. The question is how we can build consensus in the scientific community and among our allies, and how we can build coalitions to pull those policy levers more effectively.”

At the end, Farmer poked a little fun of himself, as he often does.

“I’m sorry if I sound like an Old Testament prophet,” he said. “But I feel like I’m with the home team.”

By John Donnelly

A decade ago, many global health experts trying to develop new drugs, vaccines, or diagnostic tools admitted they had a market failure. Industry dropped projects because they couldn’t be assured of making a profit. Researching solutions for diseases affecting mainly the poor started to dry up.

The crisis led to the formation of several groups called Product Development Partnerships, or PDPs. They were tasked to hunt for promising research, possible players, and funders, under the theory that together the actors could produce a breakthrough unattainable to a group working alone.

In a session Tuesday at the ASTMH annual meeting in Philadelphia, representatives from PDPs; biotech and pharmaceutical companies; NGOs; and the World Health Organization talked about successes from the collaborations – as well as suggestions on ways to improve the model.

Dr. Robert D. Newman, director of Global Malaria Programme at WHO, said that PDPs such as Medicines for Malaria Venture (MMV), the Foundation for Innovative New Diagnostics, and the Malaria Vaccine Initiative have been invaluable. “From the seat I sit in, there is an array of PDPs that have been essential to the progress we have made and we will need in the future,” he said.

He said it was urgent to produce new malaria drugs given the findings of resistance to artemisinin along the Cambodia-Thailand border, a development that malaria experts believe is likely the start of an eventual spread of resistance around the world.

“We need to be working on new medicines,” Newman said. “But without PDPs, we would not have this pipeline (for drugs and vaccines) we have in place today.”

Two representatives of industry -- Dr. Yves Ribeill, CEO of SCYNEXIS, a Durham, N.C.-based biotech firm, and Silvio C. Gabriel, executive vice president and head of Malaria Initiatives at Novartis Pharma – said their PDP experiences were fruitful but they also suggested improvements.

Both teamed with multiple partners – SCYNEXIS on a drug candidate for Human African Trypanosomiasis, or sleeping sickness, and Novartis on several malaria drugs, including a pediatric formulation.

Ribeill said that 50 percent of new drugs for neglected diseases were the result of biotech innovation and “if we want to make a greater impact, biotechs can play a very strong role.”

The sleeping sickness project, which was managed by Drugs for Neglected Diseases initiative, needed many pieces to come together, he said. It required $15 million in funding over three years; a partner, Anacor, to provide technology due to a “very motivated CEO;” and his motivation and those of scientists at SCYNEXIS, including “some who asked not to be taken off the project and if they had to leave it, they said they were willing to work for free.” In all, he said, 19 people were working on the project, which has produced a drug candidate that will enter clinical trials next year.

Novartis’ Gabriel said pharmaceutical companies needed to make clear-eyed assessments about the economics of a project as well as how it would affect the company reputation. In the end, his collaboration with MMV and others produced more than 400 million treatments of malaria medication. That was his bottom line, he said, but he added that Novartis did not make money on the venture and at the beginning it absorbed a reputational hit when Doctors Without Borders led a protest that Novartis was not producing more malaria drugs.

The truth, he said, was that it took 14 months to produce the drugs from the manufacturer, and Novartis was given a 12-month deadline. Other issues, he said, was the poor forecasting on the need for malaria drugs. In 2005, for instance, Novartis was asked to produce 30 million treatments but only 9 million were used.

His lessons: the project should plan not just research and development but also include what is best for the patient; support from a company CEO was essential; partners need to share the same values; all have to contribute; and a “great team is needed.”

“For me, this was the most fascinating job I ever did,” Gabriel said. “For my personal life, this was the best experience I ever had.”

By John Donnelly

A group of health experts said Tuesday at the ASTMH’s annual meeting that “success is at hand” for the introduction of a dengue vaccine to the developing world by 2015.

With one vaccine candidate in a Phase III trial, and a number of other candidates in the pipeline, Richard T. Mahoney of the International Vaccine Institute in Seoul, Korea, said that the vaccine will be introduced in the developing world first because of demand. More than 100 countries in the developing world have cases of dengue fever. An estimated 500,000 to 2.1 million severe cases of the painful disease occur every year, causing 18,000 to 21,000 deaths annually.

“This will not be the usual experience,” Mahoney said, referring to the rollout in developing countries. “Thus, it is essential and especially important that planning for the introduction of a dengue vaccine begins now. In fact some people would say we are behind the times.”

Mahoney said the effort, though, already has involved outreach to several countries, and some, such as Brazil, would be ready to introduce a vaccine soon after the World Health Organization approves it.

He said the vaccine also would be available in developed countries in traveler’s clinics, and that those leading the effort expect that the US military would put in a large order for the vaccine in order to protect troops going to dengue-infected regions.

Dengue fever had been a rarity in the United States until the last decade. A study found that from 2000 to 2007, 1250 patients were hospitalized in the US with dengue fever.

Several panelists said that the cost of a vaccine would be critical to the introduction in most developing countries. Right now, the panelists said, they do not know the cost of the vaccine.

But Dagna O. Constenla, associate scientist at the Johns Hopkins Bloomberg School of Public Health’s Department of International Health, said that preliminary modeling on the cost showed that a 16 percent reduction in costs could result in a 60 percent increase in coverage.

By John Donnelly

Karen A. Goraleski, ASTMH’s executive director, spoke Monday at a Society session titled “The Global Health Funding Landscape: Who and What You Need to Know and Why.” Afterward, in an interview, she talked about why advocacy is so important for global health during tight financial times.

Q: What are your top messages on this subject to members of the Society?

A: The first thing is that scientists are close to invisible in our society. Scientists are used to operating behind the scenes, collaborating, researching. Because of that, they are not well known. The public supports research. They want better health. What scientists can do is use that positive public opinion for the advancement of science by talking about why this investment works for the United States and the rest of the world.

Q: Why does it work?

A: There are a few reasons. One is national security. The advancements made by the Department of Defense’s military research can protect our soldiers, but they also protect travelers who are going to take vacations in exotic places. They protect the church group going overseas to build a health center or work on some other project. They protect students traveling overseas and business travelers. This helps mainstream America.

Another reason is there is an economic advancement through this research. Because we are helping create healthier communities overseas, that will lead to stronger economies around the world, and that leads to less of a dependence on the US. That is a long-term view. That is an investment in the future.

Q: How do scientists make this case in a way that has impact?

A: Not every researcher is going to meet with a member of Congress. But you can talk about the value of what you do in your own community. You can talk at a PTA meeting, a Kiwanis meeting, at your kids’ high school. You might want to write in local newspapers about what a NIH-funded scientist does. And members of Congress are very interested in what this is doing for their constituents, and talking about good paying jobs because of research is one way you will really get an elected person’s ear.

Q: Where do things stand for global health research funding in Washington?

A: We are in very serious times -- both at the kitchen table and at the research lab. The funding for global health research, which includes tropical medicine research and development, is a miniscule amount of the federal budget. I think there is a common misperception among the American public as well as some members of Congress that this is an enormous amount of investment. In reality, it is what is called ‘decimal dust’ in Washington, D.C. We are getting an incredible return from the investment in global health, all the lives saved, and all the lives improved. No country wants to be dependent on someone else. Every family – American families, Somali families, Peruvian families-- are the same: We all want better health for our children and for our grandchildren. The American public understands this, too. But strident voices have taken over the media and have blurred some of the facts.

Q: What is the economic case in the US for supporting global health?

A: This creates jobs throughout the United States. Those research dollars, which by the way are eroding, pay the salaries of many people. Those jobs are the direct benefits of this investment. But there are many indirect benefits, too. If a researcher gets a job at a university, he or she moves to that state, buys a home, buys a car, pays taxes, send kids to school, goes to coffee shop, sends packages with the FedEx guy. There’s a huge indirect economic benefit to this research.

Q: What about students becoming more effective advocates by telling their stories?

A: Advocacy has been a growing activity for the Society, and there has been discussion at the leadership level of tapping into this interest of students. We want to engage them in advocacy in organized ways as well as encouraging them to be creative in their activism on their campus and research facilities.

By John Donnelly

The first widescale clinical study on the causes of severe diarrhea in young children found that five pathogens are the source of roughly half of the cases, according to preliminary results from seven sites in Africa and Asia released Monday at the ASTMH annual conference in Philadelphia.

The Global Enteric Multi-Center Study (GEMS) of Severe Pediatric Diarrheal Disease’s results are expected to influence policymakers as well as future research. Until now, no large study had pinpointed the causes of diarrhea, which kills an estimated 2.2 million children annually. The study looked at 37 causes of diarrhea.

The No. 1 cause of diarrhea in children in their first year was rotavirus, accounting for between 25 and 33 percent of all cases, according to the study. The other leading causes were Cryptosporidium; EFEC LT/ST or Enterotoxigenic E. coli; and shigella.

For older children, up to five years old, those four causes also were present (shigella was most common among children from two to five years old), but other major causes were Aeromonas and cholera.

Among the surprises, according to researchers, was the prevalence of Cryptosporidium; finding cholera in children at a younger than expected age; and a fatality rate that was six to seven times greater for children with moderate to severe diarrhea compared to a less serious type. The study also found that nearly 60 percent of the fatalities occurred at home.

Dr. Myron M. Levine, the coordinating investigator of the project, said he saw several possible outcomes from the study.

“Because only a handful (of causes) account for about half of the disease, it suggests that a package of a relatively small number of specific interventions may be able to substantially reduce mortality and morbidity from diarrheal diseases,” Levine told the session.

On the rotavirus vaccine, Levine said: “Let’s get that rotavirus vaccine into countries in sub-Saharan Africa” more quickly. “Let’s also implement cholera vaccines in high-risk areas in South Asia, and Mozambique. And let’s expand the use of oral rehydration solution and expand the use of zinc in Africa.”

He also believed that the results could help spur more research into Cryptosporidium as well as possibly other pathogens that cause diarrhea.

By John Donnelly

Dr. Gerald Keusch had a challenge for an ASTMH panel: He wanted them to think broadly about how the field of global health has changed in the last decade, and he wanted their vision for the future.

“Global health is evolving and it’s more than just about diseases. It’s really about health,” said Keusch, former director of the Fogarty International Center and now professor of Medicine and International Health at Boston University. “It’s not just about the old goals of conquering malaria, or the major disease of our interest. It’s about setting new goals. … It’s not just about discovery and knowledge, it’s about using discovery and knowledge. It’s not just about capacity building, it’s about developing partnerships. It’s not just about doing stuff, it’s about doing stuff right.”

Five themes emerged from the discussion:

Tackling cancer and other non-communicable diseases. Dr. Harold E. Varmus, former director of the National Institutes of Health and now heading the NIH’s National Cancer Institute, said the focus of global health was expanding rapidly to do more against cancer and other non-communicable diseases. He pointed out how cancers were often associated with infectious diseases, notably HIV in sub-Saharan Africa; that the fight against cancer should learn from the prevention efforts against tobacco, obesity, and alcohol; and that surgical capacity in the developed world is the “neglected stepchild of public health.”

An explosion of student interest in global health. In just a few years, for instance, the Consortium of Universities for Global Health has grown to 59 universities as members, said Dr. Jeffrey P. Koplan, former head of the Centers for Disease Control and Prevention and Vice President for Global Health at Emory University. “Students are driving this all across the country,” he said. Some examples: Emory has 1,405 students studying global health from 40 countries; John Hopkins has 2,287 students from 86 countries; and the University of Washington has 1,266 students from 15 countries.

Ethical issues growing in importance:  Nancy E. Kass, a bioethicist at the Bloomberg School of Public Health at Johns Hopkins University, said that following the work of HIV/AIDS activists who fought to expand access of antiretroviral drugs in the developing world, countries became much more active around ethical issues associated with clinical trials. Now, she said, there has been a dramatic increases in the number of local Institutional Review Boards; the number of professionals training others on ethics challenges; and Community Advisory Boards, which have given local input about scientific studies.

The rise of Product Development Partnerships (PDPs). Maria C. Freire, former President and Chief Executive Officer of the TB Alliance and now President of the Albert and Mary Lasker Foundation, recalled how the TB Alliance, a PDP, started to look for new TB drug candidates in 2000. It found almost no new compounds for new TB drugs. It then approached pharmaceutical companies and research institutes around the world and secured rights of old drugs to test them for TB. “Each one of our agreements was different,” she said. “We were flexible and innovative. We retained all the rights for TB for the field of use, for the patents. We also wanted rights to use it for TB and other neglected diseases, if we could get that. We wanted the whole field to have them and make sure others could use them.” Now, one decade later, the TB Alliance is testing nearly 10 drug candidates, some of them in combination with each other. PDPs are matchmakers of a sort, bringing together unlikely partners such as pharmaceutical companies, government officials, and university scientists to find new drugs, vaccines, and diagnostic tools for neglected diseases.

Building new partnerships in research. Dr. Zulfiqar A. Bhutta, founding chair of the Division of Women and Child Health at the Aga Khan University in Pakistan, talked about how a $40 million program over 20 years from the United States to Pakistan funded 230 research grants in 17 countries, and created a network of 200 scientists. He pinpointed one piece of that program, a $1.7 million initiative from 1987 to 1993 that led to 40 research projects. And then he traced the careers of eight scientists trained under that program. Three of them, he said, have become global leaders in their fields. The other five, he said, are playing leadership roles in public health in Pakistan. “When you look at the impact of these grants,” Bhutta said, “you see a multiplier effect. The project was one of the most successful strategies into developing human capacity.”

By John Donnelly

When Abdulrazzaq Habib was growing up in northern Nigeria, he learned that the name of a deadly snake, the carpet viper, was called gobe da nisa in the Hausa language, which in English means “tomorrow is far.”

“It meant that death could come, and you may not survive until tomorrow,” Habib said, following a session on the global health burden of snakebites at the ASTMH annual conference on Monday. Several presentations documented the depth of the problem and how under-reported it is in the developing world.

The World Health Organization estimates that up to 5 million people are bit by snakes every year, resulting in 100,000 deaths and 300,000 permanent disabilities.

Habib and others said that the main reason for under-reporting is that many snakebite victims never reach health facilities. Many receive treatment from local healers, or “snake charmers,” including one study in Bangladesh that showed 86 percent of victims did not go to a health facility.

“It’s largely invisible because it’s a problem mostly of people of lower socioeconomic status from rural areas,” Habib said. “These people often don’t have good knowledge about what to do about snake bites, they are rural and poor. They are really voiceless.”

In northern Nigeria, though, Habib said a treatment center set up at Kaltungo Hospital by David Warrell of the University of Oxford, who has studied snake bites in West Africa for four decades, has greatly helped treat victims. “People go there because they all know about it,” he said. “It’s been active for more than 30 years.”

The hospital receives up to 40 to 50 snakebite patients a day – too many for the available beds, and many sleep on the floor or on the veranda. Some of the most common snakes in Nigeria are the carpet vipers (including a white-bellied version), spitting cobra, and adders. Farmers, cattle herders, mothers, children all come in, he said. Most were barefoot when bit. Many were bit near homes or storage sheds.

 “The rodents go to where food is stored,” Habib said, “and snakes follow the rodents.”

Warrell said the damage from snake bites often is quite extensive, requiring surgery.  “Large areas of skin can be lost,” he said. “You often need skin grafting as wound healing is very difficult when faced with such an extensive loss of skin.”

He also said that snake venom “doesn’t contain one toxin, it contains four or five all acting together,” and when human blood is mixed with snake venom, the blood quickly clots.

Habib said among the next steps needed was to ensure a supply of reliable anti-venoms for health facilities; educating communities about the dangers of snake bites; and conducting more research about the best types of anti-venoms for specific regions of the world.

By John Donnelly

The recent decision by the board of the Global Fund to Fight AIDS, tuberculosis and Malaria to cancel its next round of funding was "the single biggest setback" in fighting infectious diseases in the last decade and could result in a major scaleback of programs, renowned economist Jeffrey Sachs warned in the keynote address at the ASTMH 60th Annual Meeting opening plenary session tonight in Philadelphia.

In November, the Global Fund's board canceled the next round of funding and said that new funding wouldn't be considered until 2014 because of what it called deep uncertainties in future donor pledges. Still, the Fund expects to disburse roughly $10 billion from 2011 to 2013 from earlier commitments.

But Sachs, whose economics research and advocacy starting more than a decade ago for greater spending in global health helped lay the groundwork for the formation of the Global Fund, called on those working in global health to contact senior health policymakers to urge a continual scale-up of the Fund's grants.

If the cuts go through, "it's game over" for the Millennium Development goals in 2015, the United Nations' goals to fight poverty, he said. "The effective interventions, including ones that you have pioneered, are all at risk. ... Now, not only are we not having a breakthrough, we are at the edge of collapse after 10 years of work."

"I would like the Society to take this on and contact people of responsibility," Sachs said. Policymakers who decided against increasing funding for the Global  Fund "do not feel very good about this, but we should make them feel worse about it."

Sachs took aim at U.S. Democrats and Republicans for their lack of support in global health. He singled out President Barack Obama for what he called his lack of leadership in not building upon the successes of his predecessor, George W. Bush.

"We have a lack of White House leadership, I'm afraid," he said. "While President Obama spoke out on HIV/AIDS on World AIDS Day, it was a long time before we heard him speak on these issues. We don't see the commitment of President Obama, even the commitment that George W. Bush had."

Sachs paused. "I can't tell you how hard it is to say that sentence," he said, to some laughter in the audience. "It is very, very serious. It is ironic. George W. Bush was scaling up, and Obama, at best, is barely holding on."

He was even more biting in his assessment of the Republican presidential candidates for their lack of support for foreign aid overall. "They are a phenomenon," he said of the 2012 GOP field. "Something has gone so wrong in the water supply before these debates that we are hearing delusional statements all the time. One of them is that we should cancel all foreign aid. This is what we are facing now: almost an onslaught to the basic notion that America should contribute a tiny cost of the health and survival of the world's poorest people."

He said he was fully aware of the global economic crisis but he believed that perspective was necessary when looking at the Global Fund's decision not to consider new grant requests for the next three years.

"You might say it's a financial crisis, but I remind you what the U.S. pledge for 2011-13 is: $4 billion over three years," Sachs said. "We spend $1.9 billion a day on the military. We are talking about two days of military spending that would cover the three years to fund a pledge at the Global Fund."

By John Donnelly 

The president of the American Society of Tropical Medicine and Hygiene says that most of the scientists and researchers gathered at the annual meeting in Philadelphia likely underestimate their collective impact in the world.

"There's so much talk about solving global problems, and I don’t think people realize how powerful we are as a group," said Dr. Peter J. Hotez, professor of Pediatrics and Molecular Virology and Microbiology at Baylor College of Medicine and founding Dean of the National School of Tropical Medicine. "We are solving some of the most common infections of the world’s poorest people."

Hotez, in an interview, said that reducing diseases of the poor has multiple positive effects. "These are the diseases that trap the bottom billion in poverty," he said. "These diseases reduce future wage earning. … And these diseases are major contributors to the world’s global conflicts – if you made a global map of conflict and disease, you would see a lot of overlapping – so solving the diseases" has the potential to reduce drivers of conflict, he said.

He said the meeting, which will attract roughly 3,500 people, is an obvious opportunity for networking and seeking new collaborations, adding: "The sum is much bigger than its parts. We’re a major force the world's scientists working to find solutions to the major diseases that afflict the world’s poorest people."