Care Over Neglect: Neglected Tropical Diseases in South-East Asia Region

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MJWFƺ - Dr Tedros Adhanom Ghebreyesus, Director General

ƹ+COOQTGEQPXKPEGFVJCPGXGTQPVJGGNKOKPCVKQPQHPGINGEVGFVTQRKECN FKUGCUGU6JGSWGUVVQCEJKGXGWPKXGTUCNJGCNVJEQXGTCIGCPFNGCXKPIPQQPG DGJKPFKUKPEWODGPVQPGNKOKPCVKPI06&Uƺ - Dr Poonam Khetrapal Singh, Regional Director

Care Over Neglect: Neglected Tropical Diseases in South-East Asia Region ISBN 978-92- 9022-612- 3 © World Health Organization 2017

Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercialShareAlike 3.0 IGO licence (CC BY-NC- SA 3.0 IGO; https://creativecommons.org/licenses/by-nc- sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no VXJJHVWLRQWKDW:+2HQGRUVHVDQ\VSHFL¿FRUJDQL]DWLRQSURGXFWVRUVHUYLFHV7KHXVHRIWKH:+2ORJRLV not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with WKHVXJJHVWHGFLWDWLRQ³7KLVWUDQVODWLRQZDVQRWFUHDWHGE\WKH:RUOG+HDOWK2UJDQL]DWLRQ:+2:+2LV not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the PHGLDWLRQUXOHVRIWKH:RUOG,QWHOOHFWXDO3URSHUW\2UJDQL]DWLRQ Suggested citation. Care Over Neglect: Neglected Tropical Diseases in South-East Asia Region. New Delhi: :RUOG+HDOWK2UJDQL]DWLRQ5HJLRQDO2I¿FHIRU6RXWK(DVW$VLD/LFHQFH&&%<1&6$,*2 Cataloguing-in- Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as WDEOHV¿JXUHVRULPDJHVLWLV\RXUUHVSRQVLELOLW\WRGHWHUPLQHZKHWKHUSHUPLVVLRQLVQHHGHGIRUWKDWUHXVH and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any thirdparty- owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full DJUHHPHQW7KHPHQWLRQRIVSHFL¿FFRPSDQLHVRURIFHUWDLQPDQXIDFWXUHUV¶SURGXFWVGRHVQRWLPSO\WKDWWKH\ are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.

Foreword +VKUCOCVVGTQHITGCVEQPEGTPVJCVINQDCNN[VJTGGDKNNKQPRGQRNGƴCNOQUVJCNHVJGYQTNFƷURQRWNCVKQP ƴ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ƴN[ORJCVKEǣNCTKCUKUUQKNVTCPUOKVVGFJGNOKPVJKCUKUNGRTQU[XKUEGTCNNGKUJOCPKCUKU MCNCC\CT[CYU UEJKUVQUQOKCUKUCPFVTCEJQOCƴEQWNFCNNDGGNKOKPCVGFKPVJGPGCTHWVWTG9KVJ9*1ƷU06&TQCFOCR CPFVJG.QPFQP&GENCTCVKQPQHVJGYQTNFKUEQOOKVVGFVQVCEMNKPI06&UKPCEQPEGTVGF EQNNCDQTCVKXGYC[(QTEGPVURGTRGTUQPRGT[GCTYGECPGPFVJGFGURCKTCPFFGCVJU6JGJWOCP RQVGPVKCNQHJGNRKPIUQOCP[RGQRNGDGEQOGJGCNVJ[KUUVCIIGTKPI9GJCXGEQOGCNQPIYC[VQYCTFU IGVVKPIVJGTGCPFYGCTGPQYCVCETKVKECNOQOGPV+PQXGTCDKNNKQPRGQRNGKPEQWPVTKGU TGEGKXGFRTGXGPVKXGVTGCVOGPVHQT06&U 9KVJCEQORNGZEQODKPCVKQPQHVGEJPQNQI[TGUGCTEJJWOCPECRKVCNKPPQXCVKQPRCTVPGTUJKRUCPF ǣPCPEKCNCPFOQTCNEQOOKVOGPVUYGJCXGCNTGCF[UGGPUQOG06&UDGKPIGNKOKPCVGFKPUQOG/GODGT 5VCVGUƴUWEJCUN[ORJCVKEǣNCTKCUKUKP5TK.CPMCCPF[CYUKP+PFKC6JGIQQFPGYUKUVJCVGXGT[QPGQH VJGUGFKUGCUGUKUGCUKN[VTGCVGFQTRTGXGPVGF#DQWVQHCNN06&UECPDGVTGCVGFYKVJOGFKEKPGUVJCV RCVKGPVUPGGFQPN[QPEGQTVYKEGC[GCT#PFGXGT[UKPINGQPGQHVJGOJCUNQQUGPGFKVUITKR 9GECPGPF06&UKPCNN/GODGT5VCVGUQHVJG9*15QWVJ'CUV#UKC4GIKQP+VƷUGRKFGOKQNQIKECNN[ VGEJPQNQIKECNN[CPFJKUVQTKECNN[HGCUKDNG9GMPQYYJCVYGPGGFVQFQ)QXGTPOGPVUCPFRCTVPGTUCV GXGT[NGXGNCTGEQOOKVVGF#VVJKUOQOGPVKPJKUVQT[YGJQNFHWVWTGIGPGTCVKQPUƷYGNNDGKPIKPQWTJCPFU

Dr Poonam Khetrapal Singh Regional Director

CONTENTS *QYVJG1VJGT*CNH.KXGUƿ1T&KGU

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GSK, Nepal

How the Other Half Lives… Or Dies ;QWCTGNQQMKPICVCPGZGTEKUGKPEQPVTCFKEVKQPUCEQǢGGVCDNG DQQMCDQWVPGINGEVGFVTQRKECNFKUGCUGU 06&U%JCPEGUCTG KH[QWJCXGCEQǢGGVCDNG[QWJCXGPGXGTUWǢGTGFHTQOCP 06&#PFVJCVKURTGEKUGN[VJGRQKPVQHVJKUDQQM

 

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il Maya lives with 21 family members in the Palpa district in western Nepal. When she was six years old, she developed blisters on her legs. Six years and many misdiagnoses later, UJGYCUǣPCNN[VQNFUJGJCFNGRTQU[ and now she is getting correctly treated. Although her treatments interfere with school, she is a smart and driven high-schooler and on track to become a nurse. Dil Maya is one of more than a billion RGQRNGCǢGEVGFD[06&UCFKXGTUGITQWR QHEQOOWPKECDNGFKUGCUGU6JTGGDKNNKQP people are at risk. About 500 000 people FKGQHCP06&GCEJ[GCT

06&UJCRRGPVQRQQTRGQRNGVJQUG YJQUGXQKEGUCTGPƷVJGCTF6JG[CTG diseases of the socially marginalized, CPFCURCTVQHVJGKTETWGNGǢGEVVJG[ create even more marginalization. Just look at the beggar with limbs eaten by leprosy, or the child with a face covered with yaws ulcers, and you will agree. Just look at the laws that say leprosy is UWǥEKGPVITQWPFUHQTFKXQTEG,WUVNQQM CVVJGǣNCTKCUKUXKEVKOYJQECPPQVUJQY her “elephant”-like leg in public. (QTEGPVURGTRGTUQPRGT[GCTYGECPUVQRKV 6JGJWOCPRQVGPVKCNQHJGNRKPIUQOCP[RGQRNG IGVJGCNVJ[KUUVCIIGTKPI9GJCXGEQOGCNQPIYC[ VQYCTFUIGVVKPIVJGTGCPFYGCTGPQYCVCETKVKECN OQOGPV+PQXGTCDKNNKQPRGQRNGKP EQWPVTKGUTGEGKXGFRTGXGPVKXGVTGCVOGPV For too long, these diseases have been neglected, in spite of the fact that they cause more grief than malaria or VWDGTEWNQUKU6JCVKUTCRKFN[EJCPIKPI and the seven diseases mentioned in this book could all be eliminated in the near future. But we must keep at it. 06&UCTGNKMGFTCIQPUQTOQPUVGTU in childhood fairy tales: terrifying and overwhelming but, in the end, easily conquered with the right weapons. 9KVJ9*1ƷU06&4QCFOCRCPFVJG London Declaration of 2012, the world KUEQOOKVVGFVQVCEMNKPI06&UKPC concerted, collaborative way.

INF, Nepal



:+2'LHJR5RGULJXH]

This book talks about seven NTDs ‡Lymphatic Filariasis (LF) ‡Soil-Transmitted Helminths (STH) ‡Leprosy ‡Visceral Leishmaniasis (Kala-Azar) ‡Yaws ‡Schistosomiasis ‡Trachoma



Lymphatic Filariasis (LF) Elephantiasis is caused by mosquito-borne parasites. It alters the lymphatic system and causes abnormal enlargement of body parts. In 2000, over 120 million people were estimated to be infected, with about 40 OKNNKQPFKUǣIWTGFQTKPECRCEKVCVGF*CNHQHVJGYQTNFƷU infected population are estimated to be in WHO 5QWVJ'CUV#UKC4GIKQP As many as 941.3 million people in 54 countries are at risk of LF and require mass drug administration (MDA). It is estimated that 15 years of MDA has avoided US$ 100.5 billion in personal and health system losses. +P9*1ƷU5QWVJ'CUV#UKC4GIKQPǣNCTKCUKUKUGPFGOKE in Bangladesh, India, Indonesia, Maldives, Myanmar, 0GRCN5TK.CPMC6JCKNCPFCPF6KOQT.GUVG/CNFKXGU 5TK.CPMCCPF6JCKNCPFJCXGGNKOKPCVGFVJGFKUGCUGCU a public health problem.

GSK, India



GSK, India

Soil-Transmitted Helminths (STH) Helminths are parasitic worms, which move from human faeces into soil in areas of poor sanitation. More than 880 million children around the world are estimated to be in need of treatment HQTKPVGUVKPCNYQTOU4QWPFYQTOU whipworms and hookworms are the main RCTCUKVGUECWUKPIVJKUKPHGEVKQP6JG worms, once in your system, cause loss of iron and protein, malnutrition, diarrhoea, dysentery, and untold loss of energy and productivity. It is particularly poignant that low-cost deworming and improved UCPKVCVKQPEQWNFGNKOKPCVG56*CPF allow millions of children to reach their potential. 56*KUGPFGOKEKPCNN/GODGT5VCVGU QHVJG4GIKQPCNVJQWIJ/CNFKXGU 5TK.CPMCCPF6JCKNCPFFQPQVTGSWKTG mass treatment due to low prevalence.



Leprosy Leprosy is a chronic disease caused by a bacillus. It can lie dormant for years. +VCǢGEVUVJGUMKPVJGRGTKRJGTCNPGTXGU the respiratory tract, and the eyes. If untreated it leads to permanent disability NKOKVKPIRCTVKEKRCVKQPQHVJGRGTUQPCǢGEVGF in activities of daily living, but is completely curable with multidrug therapy. Leprosy is close to having a happy ending – the prevalence has dropped by 99% over the past three decades. Leprosy is steeped in myth and stigma. Leprosy is endemic in all 11 Member States QHVJG4GIKQPYKVJ+PFKCCPF+PFQPGUKC accounting for 68% of globally reported cases in 2015.

WHO



GSK, India

Visceral Leishmaniasis (Kala-azar) Kala-azar is caused by a parasite spread through a tiny HGOCNGUCPFǤ[/QUVKPHGEVGFRGQRNGFQPƷVFGXGNQRCP[ symptoms, but those who do have fever and enlargement of the spleen and liver, anaemia and weight loss. Later EQORNKECVKQPUKPENWFGFKUǣIWTKPITCUJGUCPFDWORUQP the skin. Kala-azar is almost always fatal if untreated but, like the other diseases mentioned here, easily treatable. Over 600 million live in endemic areas and are at risk of infection. Kala-azar is endemic in Bangladesh, India and Nepal KPVJG4GIKQPYKVJURQTCFKEECUGUTGRQTVGFHTQO$JWVCP CPF6JCKNCPF



Yaws Yaws, a poverty-related chronic skin disease caused by a bacterium spreading from person to person by skin contact, is one of the most tragic of diseases. Most sufferers are children. They develop painful ulcers and swelling. <DZVÀRXULVKHVLQXQK\JLHQLFFRQGLWLRQV adding insult to the injuries of poverty. The tragedy also lies in the fact that all it takes to VWRSWKHGLVHDVHLVRQHGRVHRID]LWKURP\FLQ so there is no reason for anyone to suffer. Yaws has been eliminated in India. Indonesia DQG7LPRU/HVWHDUHWKHWZRUHPDLQLQJ countries in the Region endemic for yaws.

WHO



MoH, Indonesia

Schistosomiasis Schistosomiasis is a chronic disease caused by parasitic worms, spread through fresh water infested with the larval form of the parasite. Freshwater snail act as intermediate host. 6JGYQTOUGPVGTJWOCPDQFKGUCPFECWUG immune reactions as well as organ damage. 6JGFKUGCUGKUYKFGURTGCFKP#HTKEC Large-scale treatment is the best way to reduce illness and prevent transmission. Any treatment must go hand-in-hand with the availability of safe water. Schistosomiasis is endemic only in Indonesia KPVJG4GIKQP



Trachoma 6TCEJQOCKUCDCEVGTKCNKPHGEVKQPURTGCFKPIHTQO person to person, and one of the leading causes QHDNKPFPGUU6JGKPHGEVKQPKUQHVGPCESWKTGFKP EJKNFJQQF4GRGCVGFKPHGEVKQPUQXGTVJG[GCTU leading to scarring of the inner eyelid and cornea result in irreversible eye damage and blindness. 6JGFKUGCUGVJTKXGUKPEQOOWPKVKGUYKVJETQYFGF households, poor hygiene and inadequate YCVGTCPFUCPKVCVKQPCEEGUU6JKUEQWNFGCUKN[ be prevented by treating the communities at risk with azithromycin tablets and improving environmental conditions. 6TCEJQOCKUGPFGOKEKP+PFKC/[CPOCTCPF 0GRCNKPVJG4GIKQP

NNJS, Nepal



GSK, India

Disability; discrimination; malnutrition; anaemia; stunted growth; social stigma; chronic pain; lost income; NQUVNKXGU6JGVKP[RCTCUKVGUECWUG GPQTOQWUUWǢGTKPICPFRTG[QPVJQUG left behind. And, with the implacable logic of disenfranchisement, they FKURTQRQTVKQPCVGN[CǢGEVVJQUGYJQECP ǣIJVNGCUVYQOGPCPFEJKNFTGP 6JGIQQFPGYUKUVJCVGXGT[QPGQHVJGUG diseases is easily treated or prevented. It’s not easy but it IS simple – about 90% of CNN06&UECPDGVTGCVGFYKVJOGFKEKPGU that patients need only once or twice a year. And every single one of them has loosened its grip as the world comes together to make sure that whether or PQV[QWJCXGCEQǢGGVCDNG[QWYKNNPQ longer be in danger of these “dragons”. While inequity, marginalization, and lack of access and agency are the biggest factors, many things get in the YC[QHGPFKPI06&UQPEGCPFHQTCNN %QPǤKEVURQRWNCVKQPITQYVJYKVJQWV adequate infrastructure, migration, lack of vector control (e.g. mosquito control programmes), resistance to medicines and pesticides, lack of capacity to scale up treatment programmes … as if all this KUPƷVDCFGPQWIJTGUGCTEJKPVQ06&U has never been particularly fashionable in the hallowed halls of academia and global health management. Plus, the planet is warming and getting

increasingly hospitable to all these parasites at the same time as climate change exacerbates all the other obstacles. ,WUVCUYGJCXG06&UYGCNUQJCXG5&)U ƴVJG70ƷU5WUVCKPCDNG&GXGNQROGPV)QCNU CPCODKVKQWUCIGPFCHQTRNCPGVCT[RTQURGTKV[ )QCN)QQF*GCNVJCPF9GNN$GKPIKPENWFGU VJGNQHV[CKOQHNGCXKPIPQQPGDGJKPFIKXKPI 06&UCRNCEGKPVJGINQDCNCIGPFC9*1ƷU 06&4QCFOCRRTGUGPVUCFGVCKNGFDNWGRTKPVHQT GNKOKPCVKPICPFGXGPVWCNN[GTCFKECVKPIUQOGQH VJG06&U We can slay these seven dragons in the 11 countries of WHO South-East #UKC4GIKQPƴ$CPINCFGUJ$JWVCP &GOQETCVKE2GQRNGƷU4GRWDNKEQH-QTGC India, Indonesia, Maldives, Myanmar, 0GRCN5TK.CPMC6JCKNCPFCPF 6KOQT.GUVG+VƷUGRKFGOKQNQIKECNN[ technologically and historically feasible. We know what we need to do. Governments and partners at every NGXGNCTGEQOOKVVGF6JG[OWUV remain committed.



GSK, India

Pills, potions and pathways 9GMPQYVJCVKH[QWJCXGCP06&[QWECPOQUVNKMGN[DG UWEEGUUHWNN[VTGCVGFQTKH[QWCTGCVTKUM[QWEQWNFRTGXGPVHTQO IGVVKPIKVD[VCMKPIUQOGRKNNU6JKUUQWPFUUQUKORNG$WVVJG UKORNGCEVKQPQHIGVVKPICRKNNVQUQOGQPGKPXQNXGUXCUVEQORNGZKV[ ƴǣIWTKPIQWVYJCVRKNNVQOCMGJQYVQOCMGKVJQYVQIGVKVHTQO RNCEG#VQRNCEG$KPIQQFEQPFKVKQPCPFDGHQTGKVGZRKTGUJQYVQ RC[HQTKVCPFJQYVQOCMGUWTGKVIQGUVQVJGTKIJVRGTUQPCVVJG TKIJVVKOGKPVJGTKIJVCOQWPV

33

C

onsider albendazole, the armour against worms. In combination with DEC or ivermectin, it has transformed the lymphatic ǣNCTKCUKUNCPFUECRG(KTUVVJGTCYOCVGTKCN is found and processed in various locations CTQWPFVJGYQTNF6JGPKVKUOCFGKPVQ VCDNGVUKP#UKCPCPF#HTKECPHCEVQTKGU6JGP the pills must be safely packaged. It goes by land, sea and air and through Customs KPOCP[EQWPVTKGU6JGTGOQTGYQTMGTUKP central clearing houses dispatch medicine by truck, motorcycle boat, bicycle … any way they can, to anywhere it is needed. 6JGPKPGXGT[XKNNCIGNQECNRGQRNGQTICPK\G mass drug administration to make sure the medicine reaches everyone it should. Donating is not just a matter of waving a wand and getting the medicine where it should go. Each pill involves months of planning and production, and hundreds of people. +VƷUYQTVJVJGGǢQTV#GUVKOCVGQH VJGKORCEVQH/&#HQTN[ORJCVKEǣNCTKCUKU during the past 15 years showed that more than 36 million clinical cases and 175 million disability-adjusted life years &#.;UYGTGCXGTVGF'EQPQOKEDGPGǣVU during these 15 years alone exceed US$ 100.5 billion. Now, more than 5.6 billion courses of treatment to over 763 million people have been provided. All seven diseases in this book can be eliminated with preventive chemotherapy and transmission control, a strategy for

GSK, Nepal

mass large-scale preventive treatment or KFGPVKH[KPICPFVTGCVKPICǢGEVGFRGQRNG Some may eventually be eradicated. Eradication occurs when a disease no longer exists anywhere, the way smallpox was eradicated. Since 2012, donations of medicine from pharmaceutical companies have risen dramatically. Since 2000, more than 5 billion courses of antiparasitic treatment, mostly donated by the pharmaceutical industry, have been delivered. 8GT[IQQFFTWIUVQEQODCV06&UCTG available, and they have already played CUKIPKǣECPVTQNGKPEQPVCKPKPIFKUGCUGU But taking the medicine to where it’s needed is the next big challenge. When you’re a subsistence farmer in a remote village, transport to the nearest clinic can be prohibitively expensive. Once again, there is ample proof that tackling poverty and its attendant ills is ETKVKECNVQFGHGCVKPI06&U WHO has targeted universal health coverage by 2030. All the pills, potions and pathways need to work together as GǥEKGPVN[CURQUUKDNGVQOCMGVJKUJCRRGP 6JGRKNNUJCXGVQIGVVQVJGRGQRNGCPFVJG people have to get to the pills.



WHO

Leading the way +VVQQMOQTGVJCPJCNHCEGPVWT[DWV+PFKCFKFKV+P KVDGECOGVJGǣTUVGPFGOKEEQWPVT[KPVJGYQTNFVQDGEQOGQǥEKCNN[ CEMPQYNGFIGFVQDG[CYUHTGG6JKUKUCUVWPPKPICEJKGXGOGPV+HYG YGTGVQJQNFCPCYCTFUEGTGOQP[HQTVJQUGTGURQPUKDNGYGYQWNF PQVǣPFCXGPWGDKIGPQWIJVQǣVVJGIQXGTPOGPVQǥEKCNU9*1 CPFRCTVPGTURNCPPGTUCPFFQGTUEQOOWPKV[JGCNVJYQTMGTUCPF EQOOWPKVKGUQHRGQRNGYJQFGUGTXGETGFKV

37

Ahmed Zahid, Maldives

H

ow did they do it? By actively searching for cases before and after the monsoon rains. By timely treatment. By health education. By strong surveillance. By advocacy and public education. By mobilizing vulnerable communities. 6JGUVQT[QH[CYUKP+PFKCKNNWUVTCVGU the importance of intelligent, informed, and accountable leadership in eliminating FKUGCUGU6JGIQXGTPOGPVTGOCKPGFUVTQPIN[ focused, especially after a lapse in attention that led to a resurgence in the 1970s. From home visits to education campaigns, health RGTUQPPGNYGTGWPVKTKPIKPVJGKTGǢQTVUVQ FGVGEVVTGCVCPFHQNNQYWR6JG[DWKNVVTWUV and awareness with communities. And of course, the government provided the money necessary to train and equip health workers to serve those in need. Maldives eliminated LF and was validated in 2016, particularly remarkable given that it is made up of hundreds of islands, providing ideal living conditions for parasite-bearing mosquitoes. Continued management through sustained services and surveillance trumped geography in this case. Sri Lanka also reaped the rewards of inspired leadership in the same banner [GCTYJGPKVQǥEKCNN[GNKOKPCVGFN[ORJCVKE ǣNCTKCUKUCUCRWDNKEJGCNVJRTQDNGO+V YCUPƷVGCU[6JGECORCKIPVQGPFVJGFKUGCUG was nearly 60 years long. But it worked. 6JGIQXGTPOGPVYKUGN[FGEGPVTCNK\GFVJG campaign so that provinces could take EJCTIGQHVJGKTQYPRTQITCOOKPI6QR SWCNKV[/&#KPVJGOQUVCǢGEVGFCTGCU was coupled with social awareness and GFWECVKQPRTQITCOOGU+P6JCKNCPF joined Maldives and Sri Lanka to the list of EQWPVTKGUKPVJG4GIKQPYJQJCXGFGHGCVGF

the LF parasite and successfully eliminated LF as a public health problem. However, we cannot take any of this for granted. 6JGOKPWUEWNGQTICPKUOUVJCVECWUGVJGUG devastating diseases are still present, and DKFKPIVJGKTVKOG'XGT[CǢGEVGFEQWPVT[ must continue tracking, monitoring and reporting, and be prepared to implement GǢGEVKXGKPVGTXGPVKQPUCVVJGǣTUVUKIPQH any resurgence. 'PFKPI06&UKUC9*1(NCIUJKR2TQITCOOGHQT VJG5QWVJ'CUV#UKC4GIKQP9*1TGEQOOGPFUǣXG KPVGTXGPVKQPU ƾ 2TGXGPVKXGEJGOQVJGTCR[QHVJGRQRWNCVKQPCV TKUMKPHGEVGF ƾ +PVGPUKǣGFECUGFGVGEVKQPCPFECUGOCPCIGOGPV ƾ +PVGITCVGFXGEVQTEQPVTQNOCPCIGOGPV +8/ ƾ 2TQXKUKQPQHUCHGYCVGTUCPKVCVKQPCPFJ[IKGPG ƾ 8GVGTKPCT[RWDNKEJGCNVJ International agencies such as WHO play a key role in the process of defeating 06&U*QYGXGTVJGWNVKOCVGTGURQPUKDKNKV[ and power rests with national governments. 6JGKTEQOOKVOGPVKUVJGMG[VQGPFKPI VJGUWǢGTKPIQHOKNNKQPUQHVJGKTEKVK\GPU Planners must take so many factors into account. People cross local and international borders, and so do parasites. Populations ITQYCPFUJTKPMCǢGEVKPIFKUGCUGRCVVGTPU A woman runs away from her abusive husband in the village and goes to the city – is she carrying just her possessions, or also an invisible illness? A man migrates for work because climate change has ruined his crops – what will he bring back? A government falls, another takes over – how YKNNVJKUCǢGEVRQNKE[!2WDNKEJGCNVJKUPQV a straight line – it is more like the shifting patterns in a kaleidoscope.

 

Innovation & innovators: Information & research (KNCTKCNKPHGEVKQPUYGTGJKUVQTKECNN[VTGCVGFYKVJCNCDQTKQWU FC[EQWTUGQHFKGVJ[NECTDCOC\KPGEKVTCVG &'% 4GUGCTEJGTUTQUGVQVJGEJCNNGPIGQHYQTMKPIQWVGCUKGT VTGCVOGPVTGIKOGPUCPFFKUEQXGTGFVJCVEQCFOKPKUVGTKPI CNDGPFC\QNGYKVJGKVJGTKXGTOGEVKPQT&'%YQTMU 5KOWNVCPGQWUN[QVJGTUFGXGNQRGFCSWKEMCPFGCU[CPVKIGP FKCIPQUVKEVGUVVQTGRNCEGVJGKPXCUKXGCPFEWODGTUQOGQNF QPG0QYVJGGPFQH.(KUKPUKIJV

GSK, Indonesia

KP[RTQLGEVUKPCǢGEVGFEQWPVTKGUJWIG drug studies in the developed world, painstaking research in basement academic laboratories, health workers rowing from island to island collecting data … this is all part of VJGYQTM+PQTFGTVQGPF06&UYGOWUV understand them and know what works to stop them. Without information and research, it would remain an impossible vision and billions would become and remain sick. In the 1970s, scientists got serious about drug TGUKUVCPEGKPNGRTQU[6JG[YQTMGFQWVGǢGEVKXG OWNVKFTWIVJGTCR[ /&6/GCPYJKNGUQEKCN scientists worked on stigma, and developed public education campaigns to help victims, especially women, come out of the shadows CPFUGGMJGNR0QY/&6KUUQGǢGEVKXGVJCVKV is curing thousands of people worldwide. Viruses, bacteria, protozoa and helminths – these four pathogens are responsible for the JWOCPJCXQEYTGCMGFD[06&U+VJCUVCMGP VJGEQODKPGFGǢQTVUQHNQECNTGUGCTEJGTU funders such as the Bill & Melinda Gates Foundation, coordinating bodies such as WHO, dedicated health departments of national governments, and many, many, unrecognized health-care workers to come as far as we have. Even so, a lot of potentially useful research FQGUPQVVTCPUNCVGVQRQNKE[6JKUTGOCKPUC major public health challenge. Public health is getting increasingly inclusive. 6TGCVOGPVCRRTQCEJGUVJCVKPXQNXGRGQRNGKP the community taking ownership of their own

6

GSK, Indonesia

issues, and of recognizing and acting to solve their own health problems, show promising TGUWNVU6JKUOKIJVUGGOQDXKQWUDWVKVYCUPƷV always so, and the international community is still working out a less top down approach to GPFKPI06&U #UYGVT[VQTKFVJGYQTNFQH06&UTGUGCTEJGTU need to recognize the value of both high- and NQYVGEJKPVGTXGPVKQPU6JGTGKUCRNCEGHQT sophisticated software algorithms, and a place for bed-nets. We need to gather information for basic knowledge. We need to listen to people and understand them. We need to develop PGYOGVJQFUCPFUVTCVGIKGUHQTǣPFKPICPF treating those who don’t have the agency to do it for themselves. How do we make the best use of everything from the village gossip network to drone technology? We need to keep recalibrating our priorities to adjust to local and global shifts. 4GUGCTEJKUPQVCNWZWT[+VKUGUUGPVKCN06& research has a rich history and we must take it HQTYCTF9GECPǣPFQWVUQOWEJOQTGCDQWV diagnostics and implementation. We can be more vigilant in ensuring a rapid translation of research products into real results. 4GUGCTEJFQGUPƷVCNYC[UNQQMINCOQTQWU Scientists in laboratory coats don’t usually have Instagram accounts like rock stars. But they are the true rock stars in our odyssey to achieve universal planetary health.

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GSK, Indonesia

Partnerships 6JGFTCOCVKERNWPIGKPPWODGTUQHRGQRNGUWǢGTKPIHTQO QTCVTKUMQHǣNCTKCUKUNGRTQU[CPFMCNCC\CTFKFPQV JCRRGPKPCXCEWWOQTDGECWUGQHQPGJGTQKERGTUQPQT QPGDTKNNKCPVKFGC



Pictures: GSK, India

D

KUGCUGURGEKǣE06&RCTVPGTUJKRU drive research, prevention and VTGCVOGPV+P6KOQT.GUVGVJG-QTGCP International Cooperation Agency (KOICA) bears almost the entire cost of VCEMNKPI06&U6JG$KNNCPF/GNKPFC Gates Foundation pours millions into RWDNKERTKXCVGRCTVPGTUJKRUVQǣIJV06&U KPENWFKPI.(56*UEJKUVQUQOKCUKUCPF MCNCC\CT6JG0KRRQP(QWPFCVKQPRC[U VQǣIJVNGRTQU[$TKVCKPƷU&GRCTVOGPVHQT International Development (DFID) to ǣIJVMCNCC\CTVJG7PKVGF5VCVGU#IGPE[ HQT+PVGTPCVKQPCN&GXGNQROGPVVQǣIJV .(56*CPFUEJKUVQUQOKCUKU /KNNKQPUQHRGQRNGQYGVJGKTVTGCVOGPVVQFTWI EQORCP[FQPCVKQPU)NCZQ5OKVJ-NKPGFQPCVGU CNDGPFC\QNGHQTǣNCTKCUKUCPF56*+VRC[UHQT VJGOGFKEKPGCPFCNUQHQTVJGXGT[JKIJGZRGPUGU QHIGVVKPIVJGOGFKEKPGVQVJGPCVKQPCNYCTGJQWUG 'KUCK2JCTOCEGWVKECNUFQPCVG&'%HQTOCUU .(VTGCVOGPV,QJPUQP,QJPUQPFQPCVGU OGDGPFC\QNGHQT56*)KNGCFFQPCVGUNKRQUQOCN CORJQVGTKEKP$HQTMCNCC\CT0QXCTVKUFQPCVGU FTWIUHQTNGRTQU[/GTEMFQPCVGURTC\KSWCPVGNHQT UEJKUVQUQOKCUKU6JGNKUVIQGUQP 2CTVPGTUJKRUCNUQHWTVJGTTGUGCTEJ6JG 6TKVT[RU2TQLGEVHQWPFGFKPYCU URQPUQTGFD[6&4CPFVJG1UYCNFQ %TW\(QWPFCVKQP (KQETW\6JGRTQLGEV sequenced the genomes of three deadly parasites, including the one that causes MCNCC\CT5KOKNCTN[6TQRKECN&KUGCUG 4GUGCTEJ 6&4EQNNCDQTCVKQPUTGUWNVGFKP new tools for LF diagnosis and treatment.

6JG7-ƷU&TWIUHQT0GINGEVGF&KUGCUGU KPKVKCVKXG &0&KCNUQUVWFKGU06&U When multilateral organizations, governments, private donors, non-governmental organizations, Big Pharma and academia play well together, remarkable achievements are possible. *QYGXGTVJGDGUVCPFOQUVGǢGEVKXG partnerships come from the ground up, and involve community voices at every UVCIGQHRNCPPKPICPFGZGEWVKQP6JKU principle must always be front and centre. It isn’t always easy, but it’s increasingly common.

47

GSK, India

Intelligent investments: Health-care ÀQDQFLQJ *GCNVJECTGRTQXKFGTUCTGEQPHTQPVGFYKVJCXCTKGV[QHǣPCPEKCN EQPUKFGTCVKQPUCPFOQPGVCT[KUUWGU0QOCVVGTVJGUK\GQHCP KPUVKVWVKQPJWOCPTGUQWTEGEQUVUJKIJECRKVCNGZRGPFKVWTGUCPF KPUWǥEKGPVTGVWTPQPKPXGUVOGPVCTGKUUWGUGXGT[QPGRTQDCDN[ MPQYUCNNVQQYGNNCPFJGPEGVJGTGKUCPGGFHQTUOCTVCPF KPVGNNKIGPVKPXGUVOGPV



en-year-old Jahid had fever for months. His family took him to the Fulchari Upazila Health Complex, the closest facility to their home in Hotathpura village in Bangladesh’s Gaibandha district. Much money and several trips later, he was no better, and nobody knew why. #VVJGUCOGVKOGCǣXG[GCTQNFIKTNHTQOVJG same locality was diagnosed with kala-azar, and her case was reported to the Kala-azar 'NKOKPCVKQP2TQITCOOG -'26JG[UYWPI into action. A team came to do a house-toJQWUGUGCTEJHQTECUGUNKMG,CJKF6JGVGCO JCFCOGFKECNQǥEGTCOGFKECNVGEJPQNQIKUV CǣGNFYQTMGTCPFGPVQOQNQIKUVU6JG[NQQMGF for active cases, and screened members of 135 households. Jahid was one of the active cases. He and other patients were treated with single-dose liposomal amphotericin B at the PGCTGUVJGCNVJEQORNGZ6JG[CNNKORTQXGF after a month. A success story, this – but success, like lunches, KUUGNFQOHTGG6TCXGNVGUVKPIHCEKNKVKGUƿCNN of it costs money. While a single treatment is cheap, keeping a billion people worldwide UCHGHTQO06&UKUCXCUVGPVGTRTKUG9KVJQWV continued funding, the goal of universal health CPFHTGGFQOHTQO06&UYKNNTGOCKPCP unrealized fantasy. 6JGJGTQJGTGKUVJG)QXGTPOGPVQH $CPINCFGUJ#NNIQXGTPOGPVUKPVJG4GIKQP RTQXKFGNCTIGCOQWPVQHHWPFKPIHQT06&U taking full ownership of the programmes. National investment is crucial. Without individual government commitment and buy-in, no amount of outside help will be GPQWIJ6JGEQODKPCVKQPQHQWVUKFGCPF

6

GSK, Indonesia

domestic funds and expertise is the formula for intelligent investment. So far, governments are UVGRRKPIWR6JG[OWUVEQPVKPWGVQFQUQ 5KPEGCUKIPKǣECPVKPETGCUGKPFQPCVGF medicines has allowed WHO to scale up RTGXGPVKQPGǢQTVUCPFEQPVKPWGYKVJOCUU chemotherapy programmes. All 11 countries in VJG4GIKQPCTGKORNGOGPVKPIPCVKQPCN06& RNCPU+PVJG4GIKQPCEJKGXGF treatment coverage of school-age children for 56*GZEGGFKPIVJG9*106&4QCFOCRƷU target of 75% by 2020. 6JGRQVGPVKCNTGVWTPUCTGOKPFDQIINKPIKP terms of productivity as well as the gains to the JWOCPURKTKVHTQODGKPIJGCNVJ[6CMGYQTOU for instance. Analysis has shown that children who are dewormed when they are young and in school earn more money when they grow up than children who do not receive treatment. Supporting its commitment to the .QPFQP&GENCTCVKQPQPGPFKPI06&U the pharmaceutical industry donated US$ DKNNKQPYQTVJQH06&OGFKEKPGUKP ƴ6JGPWODGTUCTGUVCIIGTKPI since 2006, more than 5 billion courses of antiparasitic treatment, mostly donated by the pharmaceutical industry, have been delivered. 6JG7PKVGF5VCVGU#IGPE[HQT+PVGTPCVKQPCN Development and the Government of the 7PKVGF-KPIFQOJCXGǣPCPEKCNN[UWRRQTVGF CVNGCUVEQWPVTKGU6JG9QTNF$CPMJCU EQOOKVVGF75OKNNKQPVQYCTFU06&U 6JG0KRRQP(QWPFCVKQPUWRRQTVUNGRTQU[ECUG detection through the Bangkok Declaration Special Fund.



WHO

5QOGVKOGUHCTǤWPIEQWPVTKGUECPIGV together to make change happen. 6KOQT.GUVGKUUWTTQWPFGFD[EQTCN reefs. Unfortunately, its beauty and remoteness do not protect it from OWNVKRNG06&U6JGIQXGTPOGPV carried out comprehensive mapping to understand the scope of the problem. #NNQH6KOQT.GUVGƷUOWPKEKRCNKVKGU CTGGPFGOKEHQTǣNCTKCUKUNGRTQU[CPF 56*'ǢGEVKXGǣNCTKCUKUEQPVTQNTGSWKTGU mass medication. It has to be done for CVNGCUVǣXGEQPUGEWVKXG[GCTUYKVJOQTG VJCPEQXGTCIG6JGEQOOKVOGPVYCU VJGTGDWVVJGOQPG[YCUPQVUWǥEKGPV Enter the Korea International Cooperation Agency (KOICA). With the help of WHO and a national task force, -1+%#CPF6KOQT.GUVGYQTMGFQWVCP arrangement to fund implementation: the ƹ+PVGITCVGF0GINGEVGF6TQRKECN&KUGCUGU Control and Elimination Programme KP6KOQT.GUVGƴƺ7PKXGTUCN

coverage by 2030 is an ambitious goal, but not an impossible one. Financial investment is absolutely crucial, and so CTGJWOCPGǢQTVCPFRCUUKQP 6JQWUCPFUWRQPVJQWUCPFUQHJGCNVJECTG workers, many of them volunteers, make their way through jungles and deserts, endure monsoons, and cross rivers and the sea to conduct surveillance and distribute medicine. A chalk mark on a banyan tree outside a house in western Maharashtra, India, has a long story behind it: a story that has led to the workers sweating their way down a dusty road, knocking on doors to see who has received what medicine, and leaving a notation for the next person to see – all part of the far-reaching international investment in raising a generation free QH06&UCPFECTKPIHQTVJQUGYJQ CTGUWǢGTKPI



WHO

The unstoppable footsoldiers: Health workforce ;QWOKIJVUGGVJGOQPDWUGUKP$CPINCFGUJ+PVCZKUKP$JWVCP CPFHGTTKGUKP+PFQPGUKCCPF/CNFKXGU1PVTCKPUKPVJG&GOQETCVKE 2GQRNGƷU4GRWDNKEQH-QTGCCPF5TK.CPMC4KEMUJCYUKP+PFKC 2GTJCRUDWNNQEMQTFQPMG[ECTVUKP0GRCNCPF/[CPOCTKPFGǣCPEG QHVJGOKFFC[UWP1PCUEQQVGTKP6JCKNCPFQTYQDDN[DKE[ENGUKP 6KOQT.GUVG6JG[OKIJVDGECTT[KPIDQVVNGUQHVCDNGVUHQT/&# DNKUVGTRCEMUVQVTGCVRCVKGPVUQTMKVUVQVGUVUWURGEVGF06&ECUGU 6JG[CTGVJGRGQRNGQPVJGHTQPVNKPGUQHVJGECORCKIPVQGPF06&U ƴVJGWPCUUWOKPIYCTTKQTUYJQCTGUCXKPICDKNNKQPRGQRNG



GSK, Indonesia

JKNGVJGTGURQPUGVQGCEJ06& is unique, they all have this in common: community health workers who hit the road, collect data and FKURGPUGOGFKEKPG6JG[TCPIGHTQO fully licensed doctors to dedicated peers. Hundreds of thousands people work as community health workers in the 11 countries of the South-East #UKC4GIKQP Community health workers are sometimes the only outsiders who go to

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remote villages and tell people simple, important facts: worms come through contaminated water or soil; you can’t get leprosy through casual contact; or a hugely swollen leg doesn’t mean you committed a sin in your past life. And, most important of all, there is relief for all these conditions. We must continue to train, equip, pay, and appreciate, these heroes and JGTQKPGUQHVJGVTQRKEU6JG[CTGQWT DGUVJQRGHQTTGFWEKPI06&U



GSK, Indonesia

Rumah Sabat 4WOCJ5CDCVQRGPGFKPKP2CRWC2TQXKPEG Indonesia, for leprosy patients. People come here for comfort, companionship, education, OGFKECVKQPUCPFƿITGGPDGCPRQTTKFIG6JG[ learn to make handicrafts, like treasure from garbage. An apt transformation for a group that until recently was not treated with respect.



Little Doctors You’re never too young to make a FKǢGTGPEG,WUVCUMVJGƹ.KVVNG&QEVQTUƺ of Bangladesh. Little Doctors was launched in 2010 as a response to a troubling 2005 survey that showed that 80% of Bangladesh’s 25 million school children were infected with soil-transmitted helminths. Little Doctors are fourth and ǣHVJITCFGTUVTCKPGFVQCUUKUVVJGKTVGCEJGTU QPJGCNVJRTQOQVKQPFC[U6JG[JGNR VJGKTRGGTUNGCTPCDQWV56*CPFCUUKUV KPFGYQTOKPI6JG[GPEQWTCIGJCDKVWCN absentees to attend on deworming days. It’s a brilliant way to raise awareness, empower the next generation of leaders, and improve health outcomes from the ITQWPFWR6JKUHWVWTKUVKECPFGǢGEVKXG concept emerged from Indonesia in VJG4GIKQP

GSK, Indonesia



MoHFW, Govt. of India

The Leprosy Case Detection Campaign (LCDC) 6JG.GRTQU[%CUG&GVGEVKQP%CORCKIPKUQPGQHVJG many, many initiatives possible because of dedicated JGCNVJYQTMGTU9JKNG+PFKCQǥEKCNN[GNKOKPCVGF leprosy as a public health problem in 2005, it is still home to the largest number of leprosy patients – 60% of the world’s new patients in 2015. Constant attention is necessary to keep the disease under EQPVTQNCPFǣPFPGYECUGUDGHQTGVJQUGKPHGEVGF FGXGNQRFKUCDKNKVKGU6JKUKUYJGTG.%&%EQOGU in. In 2016, LCDC workers screened 320 million +PFKCPUCETQUUUVCVGU6JGGǢQTVKPXQNXGFCNOQUV 300 000 workers. 6JG5RCTUJ.GRTQU[%CORCKIPRCTVQHVJKUGǢQTV aims to decrease stigma around leprosy. Stigma is VJGWIN[CEEQORCPKOGPVVQCNOQUVGXGT[06&ƹKH you’re stupid, you get yaws; if you’re cursed, you get leprosy”. Myths abound about how you get diseases, and how you get rid of them. Health-care workers can and do help to educate people about the reality of these diseases.

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GSK, India

Crossing the divide: Service delivery 06&UCPFKPGSWCNKV[CTGCNYC[UFCPEGRCTVPGTU-CNCC\CT KP$KJCTKUCRCTVKEWNCTN[UVCTMGZCORNGQHVJKUOCECDTG RCTVPGTUJKR6JGTGQHJQWUGJQNFUKPJKIJRTGXCNGPEG EQOOWPKVKGUHCNNKPVJGNQYGUVQHYGCNVJFKUVTKDWVKQP



GSK, India

I

nternational and national partners recognize that free diagnosis and treatment is essential if we are to tackle VJGUQEKCNǣPCPEKCNCPFNQIKUVKECNDCTTKGTU to treatment. In Bihar, the kala-azar OKVTCUFGUETKDGFGCTNKGTYQTMJCTFVQǣPF information, and help people get the treatment they need.

donated by Gilead Sciences through WHO. You need dedication, yes, but you also need the drugs. WHO has just signed a new ǣXG[GCTCITGGOGPVYKVJ)KNGCF5EKGPEGU VQGPUWTGCEQPVKPWGFUWRRN[6JKUKU just one example of the many deals and agreements on the path to elimination.

6JGUCOGIQGUHQTNGRTQU[/[EQDCEVGTKWO Nepal has a cash transfer system – patients leprae has been with us for millennia, CEVWCNN[TGEGKXGCUVKRGPFYJGPVJG[ǣPKUJ and has the dubious distinction of being mentioned everywhere from religious texts their kala-azar treatment, so that they to pop songs. It was incurable until WHO are not out-of-pocket for transport and introduced multidrug therapy, a cocktail of nutrition costs. rifampicin, dapsone and clofazimine, None of it is linear. Some things work, in the 1980s. Now leprosy cases number in others don’t. But in the balance, we are the thousands rather than the millions. YKPPKPICPF06&UCTGNQUKPI +P+PFQPGUKC[QWFQPƷVǣPF $CPINCFGUJ+PFKCCPF0GRCNTKFFNGFYKVJ schistosomiasis in downtown Jakarta. It MCNCC\CTPQVUQNQPICIQCTGCNNQPVTCEMVQ occurs in Bada, Napu and Lindu valleys GNKOKPCVGKVD[6JGTGYCUPQOCIKEKPXQNXGF – three isolated areas in Central Sulawesi CNVJQWIJHQTHQTOGTRCVKGPVUVJGKTNKXGUOWUVUWTGN[ province. A strong control programme HGGNOCIKECN6JGUVTCVGI[KPXQNXGFECTGHWNCPCN[UKU started in 1973 was very successful in RNCPPKPIEQOOKVOGPVEQNNCDQTCVKQPYKVJ9*1 bringing down the prevalence, but the CPFRCTVPGTUCPFQHEQWTUGVJQUGJGTQKEJGCNVJ disease came back after the project ended YQTMGTU'CTN[FKCIPQUKUEQORTGJGPUKXGVTGCVOGPV KP6JGUGCTGTGOQVGCTGCUYKVJ CPFTKIQTQWUXGEVQTOCPCIGOGPVJCXGMGRVVJG poor water and sanitation infrastructure. UCPFǤ[HTQOEQPVKPWKPIQPKVURCVJQHFKUGCUGCPF 5EJKUVQUQOKCUKUNKMGOQUV06&UKU FGURCKT$GVYGGPCPFVJGKPEKFGPEG closely corelated with water, hygiene and QHTGRQTVGFPGYECUGUJCUIQPGFQYPD[CDQWV UCPKVCVKQPHCEKNKVKGU6JGIQXGTPOGPVJCU KP$CPINCFGUJKP+PFKCCPF committed to completely eliminating KP0GRCN UEJKUVQUQOKCUKUKPVJKU4GIKQPFGRNQ[KPI speedboats, motorcycles, and any other No, it’s not magic. In 2014, India began means necessary to get there, assess and using liposomal amphotericin B for treat where necessary. VTGCVKPIMCNCC\CT6JGOGFKEKPGYCU

67

+P/CNFKXGUVJQUGYJQCTGFKUCDNGFHTQOǣNCTKCUKU QTNGRTQU[CTGGPVKVNGFVQOQPVJN[ǣPCPEKCNUWRRQTV as a disability allowance in addition to free health ECTGCPFHQQFUWDUKFKGU6JKUKUYQTVJPQVKPI ƴǣPFKPICPFVTGCVKPIRCVKGPVUKUPƷVGPQWIJ2QNKEKGU must also include relief and safety nets for those who are irreversibly hurt. Disability and morbidity OCPCIGOGPVCTGRCTVCPFRCTEGNQHGCUKPI06&UƷ public health burden. &CVCFTKXGPRTQITCOOKPIPQVOCIKEGǢGEVKXGUGTXKEG delivery depends on this. Scientists in the laboratory CPFUQEKCNUEKGPVKUVUKPVJGǣGNFCTGDQVJPGEGUUCT[ to continue on our successful trajectory in defeating 06&U6JGRTQQHKUKPVJGHCNNKPIPWODGTU Computer modelling matters. Supply chain logistics matter. Opening the clinic on time matters. Knocking on doors matters. Lobbying for funds matters. It’s all part of service delivery. And every aspect remains a challenge. Drugs aren’t always available. People don’t always take the drugs when they are CXCKNCDNG5KFGGǢGEVUKPVGTHGTGYKVJVTGCVOGPV5CHGN[ controlling disease-carrying snails, mosquitoes and ǤKGUKUFKǥEWNV$WVVJGTGEQTFUJQYUKVƷUCNNRQUUKDNG



GSK, Indonesia

The people vs Wuchereria bancrofti .[ORJCVKEǣNCTKCUKUKPCNNKVUFKUǣIWTKPICPF FKUCDNKPIOCPKHGUVCVKQPUECWUGFWPVQNFUWǢGTKPI in Bangladesh. In 2001, the government, in collaboration with the US Centers for Disease Control and Prevention (CDC), launched the country’s elimination programme, with the goal of ending the tyranny of the mosquito-borne parasite Wuchereria bancrofti. Using WHO IWKFGNKPGUVJGǣTUVUVGRYCUVQǣPFVJGFKUGCUG 6GCOUQHYQTMGTUHCPPGFQWVKPFKUVTKEVU VQǣPFRCVKGPVU%QOOWPKV[ENKPKEUVCǢYCU trained in detection and treatment. After the mapping was complete, preventive treatment EQWNFDGIKP6JGECTGHWNU[UVGOCVKETGEQTFKPI of data and monitoring of patients is paying QǢ6JGFC[YKNNUQQPCTTKXGYJGPHWVWTG generations are ensured a life free from the agony of swollen limbs and genitalia.



GSK, Indonesia

The end in sight: Conclusion 9GƷTGPGCTN[VJGTG$WVPQVSWKVG9GECPEGNGDTCVGDWVYG OWUVPQVTGNCZ

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GSK, Nepal

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yanu Paudel sits in the sunshine knitting a pink sweater for a patient’s daughter. Gyanu is more than 80 years old. She has had leprosy for more than 70 of those years. Her hands and feet were already deformed by the time she began treatment at Green Pastures Hospital in 0GRCN5JGYCUQPGQHVJGǣTUVRCVKGPVU VJGTG#HVGTCNQPICPFFKǥEWNVNKHGUJGKU UVKNNRCTVQHVJGJQURKVCNHCOKN[6JG[JCXG seen her through marriage, motherhood, and widowhood, and she feels at home there. Gyanu gets the support she needs. If the global community executes its 06&RNCPURTQRGTN[VJGTGYKNNDGHGYGT and fewer people who have to live with a debilitating disease for eight decades. 6JKUDQQMJCUUJQPGCURQVNKIJVQPCHGY examples of what’s out there, what’s been done, and what still needs to happen. We now know that no matter which continent QTYJKEJ06&EGTVCKPVJKPIUCTGMG[ ƾ 6JGOQTGOCTIKPCNK\GFVJGITQWRVJG more we need to focus on it. ƾ Knowledge, knowledge, knowledge: the more local data, the better. ƾ Health care must be local above all. 6JGEQOOWPKV[MPQYUYJCVKVPGGFU and can deliver with the right support. ƾ Communication should suit the community whether it is television or texts or theatre in the street. ƾ We must keep up with technology and adapt it to local needs. ƾ 6JGRGTUQPCNKURQNKVKECN2WDNKEJGCNVJ who gets it and who doesn’t, is political and any health-care programme must

take this into account and attempt to foster equality. ƾ 6JKUKUCINQDCNRTQDNGOCPFKVPGGFU global collaboration in tandem with local leadership. ƾ Flexibility is important. Keep what works, tweak it as you go, and toss out what doesn’t. ƾ 0QVJKPIKURQUUKDNGYKVJQWVǣPCPEKCN support. 6JGYQTNFKUEJCPIKPICNOQUVHCUVGTVJCPKVURKPU KPKVUQTDKV#PFGXGT[EJCPIGCǢGEVURWDNKEJGCNVJ %NKOCVGEJCPIGHQTKPUVCPEGKUENQUGN[VKGFVQ 06&U/KITCPVUOQXGVQWTDCPCTGCUYJGPVJG[ NQUGVJGKTNKXGNKJQQFUCPFUQOGVKOGUDTKPIRCVJQIGPU YKVJVJGO6JKUJCRRGPGFYKVJNGRTQU[KP&JCMC 2QNKVKECNWRJGCXCNCNUQHCEVQTUKP%QPǤKEV displacement, breakdown of health systems ƿCNNVJGUGCǢGEVPQVQPN[JQYFKUGCUG spreads, but how people respond to it. Add the burdens of stigma, sexism, and the spectre of drug resistance, and it becomes a truly complicated algorithm. Given all this, we have come a remarkably long way. 6JGTGKUPQSWGUVKQPVJCVKPXGUVKPIKP JGCNVJTGUWNVUKPCHCPVCUVKERC[QǢ+OCIKPG VJGFKǢGTGPEGDGVYGGPCDKNNKQPUKEMRGQRNG who need care and cannot contribute to society, and a billion healthy people NGCTPKPIGCTPKPICPFIKXKPIDCEM6JKU FKǢGTGPEGKUCEJKGXCDNG9GƷTGPGCTN[ VJGTG$WVPQVSWKVG6JKUKUPQVKOGVQ give up.



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