The Continuing Threat of Neglected Tropical Diseases

Thank you, Chairman Smith, Ranking Member Bass, and Members of the Subcommittee for highlighting this important issue and providing me with the opportunity to discuss the U.S. Agency for International Development’s (USAID) program to combat Neglected Tropical Diseases (NTDs).

Today, roughly one billion people live in extreme poverty. While that is still an overwhelming number of people, great progress has been made. Compared to 1990, today nearly 900 million fewer people live in extreme poverty. In 2010, the world achieved Millennium Development Goal 1 – to halve the poverty rate among developing countries – five years ahead of schedule. By 2011, the poverty rate in the developing world had fallen to 17.0 percent from 43.4 percent in 1990. And the aggregate poverty rates are now falling in every region, including sub-Saharan Africa. That is impressive progress in making the world a better place. Together with our allies, President Obama has identified Ending Extreme Poverty as an important goal and USAID has incorporated it into its overall mission of partnering to end extreme poverty and promote resilient, democratic societies while advancing our security and prosperity. USAID's NTD program is an exemplary program helping the world’s most vulnerable people move from dependency to self-sufficiency and on the way to ending diseases of extreme poverty.

Today, there are still more than one billion people globally who suffer from one or more NTDs. These diseases disproportionately impact poor and rural populations, who often lack access to safe water, sanitation and essential medicines – the very people who make up those in extreme poverty. NTDs take a very heavy human toll by creating sickness, disability, blindness and severe disfigurement; contributing to childhood malnutrition; compromising the mental and physical development of children; and leading to an appreciable loss of productivity. While NTDs do not usually result in death, they clearly devastate individuals, families and the future of children.

But just like the tremendous progress that has taken place in reducing global extreme poverty, I am very proud of the substantial parallel achievements in USAID's integrated NTDs program – which started fewer than 10 years ago, with a modest mandate to demonstrate that programs could reach national scale in a handful of countries. With support from Congress, the program has made solid progress in addressing seven diseases – lymphatic filariasis, blinding trachoma, onchocerciasis, schistosomiasis and three soil-transmitted helminthes – which represent approximately 80 percent of the global NTDs burden and can be addressed through community and school-based distribution of preventive chemotherapy to all eligible individuals affected community at regular intervals, generally once or twice a year.

Some of the key achievements include:

• In the very first year of the program in 2006, USAID used $15 million to distribute 36 million treatments to 16 million people in four countries. Today, with a budget of $100 million in 2014, USAID’s program distributes 240 million treatments to 115 million people in 31 countries. To date, over 1.2 billion treatments have been provided.  In 2011, 7.7 million people no longer required treatment for lymphatic filariasis in USAID supported countries. In 2014, that increased to 92 million. And by 2018, the number is projected to jump to over 250 million, 50% of the target population.
• In Latin America, onchocerciasis is close to elimination with transmission only remaining in the hard-to-reach border area between Venezuela and Brazil.
• When compared to the World Health Organization’s (WHO) reported data, the USAID NTD program accounts for over 35% of the treatments reported globally, when middle income countries like India that primarily finance their own programs are excluded. USAID has developed, introduced and scaled-up an implementation package endorsed by WHO, which focuses on establishing policy in-country, conducting disease mapping to determine the disease burden and required drug package, distributing drugs through community and schoolbased platforms, and monitoring program performance and evaluating impact for the elimination or control of the targeted disease(s).

Integration of the treatment of diseases through community and school-based platforms has been a hallmark of the USAID program – increasing the number of people who can be reached and the number of diseases that can be addressed in the most cost-effective manner. Combining disease treatments for soil-transmitted helminthes and schistosomiasis in schools or multiple diseases during community distribution campaigns has streamlined and reduced the costs for program planning, training, education and monitoring. Integrated programs are considered the global standard, based on the success of USAID’s program.

Integrated programming is just one example of USAID’s leadership in developing cost-effective approaches that contribute to the global evidence base for tackling NTDs. All along, NTDs have relied on partnerships with communities, task shifting and public-private partnerships that have been models for other global health efforts. USAID has lead the way in developing monitoring and evaluation tools for national NTD programs to improve program monitoring across diseases, and is working with WHO and the NTD community to improve documentation of impact, especially for the elimination of lymphatic filariasis and trachoma. Country-level guidance on how to measure impact is being better defined and tested, along with the development of posttreatment surveillance systems to confirm that elimination has been achieved and no reoccurrence is taking place. Through an interagency collaboration the Centers for Disease Control and Prevention is working with USAID, WHO and our implementing partners to test various methods of post-treatment surveillance for lymphatic filariasis.

I would like to highlight a few factors that have contributed to the success of USAID’s program and the global progress to date.

First, the success of USAID’s NTD program would not have been possible without the partnership with the pharmaceutical sector. In 2014, USAID-supported countries benefited from over $2 billion in donated drugs. To date, over $8.8 billion has been generously donated from Merck & Co. Inc., GSK, Pfizer, Johnson & Johnson, and Merck Serono.

This represents an impressive leverage for our budget. We estimate that for every tax dollar spent by USAID, more than $26 in drugs is donated in-country. Conversely, the U.S. government funding plays a critical role in ensuring that systems are available to distribute the drugs. According to the Task Force for Global Health, fewer than 200 million tablets of albendazole and Mectizan, respectively, were distributed per year prior to 2006. Today, this has increased to over 800 million for albendazole and 600 million for Mectizan alone.

Second, USAID’s partnership and coordination with the government of the United Kingdom, specifically the Department for International Development (DFID), has allowed for a collective reach to almost 50 countries and the provision of 340 million treatments in 2014. This has allowed for the expansion in high-burden countries, including Ethiopia and Nigeria, and accelerated global efforts to put trachoma elimination on track by defining the burden in countries throughout Africa and Asia. Both USAID and DFID are signatories to the “London Declaration on Neglected Tropical Diseases” and together represent the primary source of funding for country programs globally. The third annual WHO report on NTDs, released in February 2015, noted that USAID, along with DFID, have been the “stalwarts of Neglected Tropical Diseases funding among traditional donor nations.”

Third, USAID builds upon the existing infrastructure of national disease control and elimination programs. USAID partners with ministries to complement existing funding, working within the context of the National Neglected Tropical Diseases Master Plans, and supporting coordination mechanisms to ensure that U.S. resources complement investments from other stakeholders and increasingly leverage domestic funding – which is a key to sustainability for diseases where the goal is disease control rather than elimination. Signs of progress are becoming visible in USAID-supported countries. Currently, eight countries have met the criteria to stop treatment for at least one disease. Further, 21 of the 31 USAID-supported countries are on track to meet the 2020 goals for one or more diseases.

Since the inception of the program, USAID has played a critical role in contributing to the global evidence for NTD programs, which has informed policy and implementation guidelines and produced new tools. Focusing on implementation is a comparative advantage of the program and fills a critical global gap. However, as the program has matured, the need to invest in new areas has arisen to ensure the WHO 2020 goals for NTDs can be achieved.

In 2014, thanks to the support of Congress, USAID expanded the NTD program to include two new components. The first programmatic change provides support for programs to address existing disability from NTDs, which leads to long-term suffering and traps individuals in poverty. Referred to as “Morbidity Management & Disability Prevention”, support provided to national programs will result in increased access to services that address the disabling complications of lymphatic filariasis, such as the acute inflammation and extreme swelling of limbs more commonly referred to as elephantiasis, and provide eye surgeries to prevent further blindness from trachoma. Approximately 40 million people have symptoms for lymphatic filariasis and four million people require surgery for trachoma. Additionally, some of these services are required for national programs to meet the WHO criteria for documenting elimination.

The second programmatic change supports research that addresses both the discovery of new drugs and operations research to accelerate progress toward elimination. USAID entered into a partnership with the Bill & Melinda Gates Foundation through the Coalition for Research on Neglected Tropical Diseases to strategically address the most pressing research questions. This collaboration includes a country-specific approach for addressing programmatic NTD issues in a timely manner. The Gates Foundation supports more early-stage research investments, while USAID support primarily focuses on programmatic or operational research needs. USAID efforts are improving monitoring and evaluation, introducing new diagnostics and developing program implementation tools. Additionally, this private sector collaboration compliments basic and clinical studies supported by the National Institutes of Health and academic institutions.

Complementing the operations research component is an investment with the Drugs for Neglected Diseases initiative (DNDi) to identify new or orphaned drugs or more effective drug combinations to accelerate progress toward elimination. This is also done in collaboration with the Gates Foundation, and seeks to complement the research efforts of other institutions. These investments fall in line with USAID’s broader emphasis on sourcing and scaling innovations – as evidenced by the creation of the Agency’s new U.S. Global Development Lab and the Bureau for Global Health's Center for Accelerating Innovation and Impact – that have the potential to leap frog conventional approaches and hasten the achievement of our development goals. The Saving Lives at Birth Grand Challenge, launched in March 2011, and the Fighting Ebola Grand Challenge, launched last fall, embody this new model of development – calling on the world’s brightest minds to solve our biggest global challenges and swiftly providing them with the financial and technical support they need to bring their ideas to impact.

Effective treatment strategies have opened the door to strengthening cross-sector approaches. School-based deworming programs have brought the education sector in as a routine partner. The NTD and water, sanitation and hygiene community are working to find ways to influence national policy to better align investments for greater impact, particularly around trachoma and soil transmitted helminthes. Coordination between national malaria and lymphatic filariasis programs is evolving. Cross-sector approaches will be essential to ensuring the long-term sustainability for NTD programs, particularly with diseases that have a control goal and require long-term strategies.

Given that the tools are available and the drugs are being generously donated the elimination of these diseases of extreme poverty as a public health scourge is within our grasp. USAID is committed to achieving the WHO Neglected Tropical Diseases 2020 Goals and working with countries and our global partners to reach the remaining 800 million people who still need treatment. We must remain focused to ensure success. The progress to date, along with generous support from Congress, has made this program a clear success and continues to put the U.S. government in a position of leading the global effort to combat NTDs.