Co-authored by Ellen Agler
Neglected tropical diseases (NTDs) and poverty reinforce each other through mechanisms that involve reductions in workforce, food insecurity, and the health of girls and women. Less well known, but equally important social forces, in promoting NTDs, are war and conflict. Previous articles have highlighted the devastation from NTDs in times of war, especially in remote areas of South Sudan and other African countries, as well as in the Middle East. For example, the NTD known as African sleeping sickness is believed to have killed hundreds of thousands of people caught in long and drawn out civil and international conflicts at the close of the 20th century.
The Central African Republic (CAR) could emerge as one of the newest "perfect storms" of poverty, conflict, and NTDs. A former French colony, CAR is a landlocked country surrounded by nations such as the Democratic Republic of Congo (DRC), South Sudan, Sudan, and Chad, which also have experienced recent and serious outbreaks of wars and violence. With just over five million people, by most metrics it is considered one of the most remote and economically devastated countries in Africa. CAR is tied with Somalia, Burundi and Zimbabwe as being ranked 224th in GDP per capita - near the very bottom.
Superimposed on CAR's crushing rural poverty is a brutal civil war targeting innocent civilians and a collapse in the government that has required the United Nations to send in soldiers and other peace keepers on top of troops already there from France and the African Union. A great public health concern affecting the country is currently African sleeping sickness. According to the World Health Organization (WHO), CAR is one of four African countries annually reporting more than 100 cases of the Gambian form of sleeping sickness which usually leads to death in two to three years.
Accordingly, Doctors Without Borders/Médecins Sans Frontières (MSF) has worked to send in mobile teams in order to identify and treat patients, presumably in anticipation of yet another humanitarian tragedy that could result from this disease due to the rising conflict.
Beyond sleeping sickness, NTDs that ordinarily could be targeted through mass drug administration (MDA) are also widespread in CAR. The WHO estimates that approximately 1.5 million children require periodic deworming for their intestinal helminth infections, of whom more than 500,000 also need regular treatment for schistosomiasis. Almost two-thirds of the country - more than three million people - requires MDA for lymphatic filariasis, and 1.6 million people live in areas where onchocerciasis is meso- or hyperendemic. In addition, Loa loa co-infections also occur in CAR and the country is endemic for blinding trachoma. Thus, CAR is one of Africa's largest sources of endemic and hyperendemic NTDs.
Currently, neither the United States nor the United Kingdom governments support NTD control and elimination programs in CAR and there is very little private philanthropic money focused on NTDs going to support such measures.
The END Fund, a private philanthropic fund dedicated to combatting NTDs, was one exception and supported NTD control efforts in CAR in 2012. Unfortunately, due to the impact that violence and instability had on the ability for program partners to move forward with mapping and MDA activities, the END Fund had to place support to CAR on hold. A key reason for the suspension was the fact that mapping and MDA activities require health workers having access to schools, health centers and communities across the country. As MDA often mobilizes thousands of health workers to treat millions of people at risk of NTDs in a short period of time, the activities can be dangerous in times of conflict. NTD control often falls off the priority list when conflict arises as agencies and governments focus on providing food, shelter and security to affected population.
To ensure that these diseases that devastate the lives of millions of people are not further neglected during times of crisis, engagement from health agencies with expertise in complex emergencies and a willingness to ensure NTD control efforts remain a priority. It is imperative that the people of CAR receive access to the essential NTD medicines they need to avoid the disability and death caused by NTDs.
Peter Hotez is Texas Children's Hospital Endowed Chair in Tropical Pediatrics and dean of the National School of Tropical Medicine at Baylor College of Medicine. He is also president of the Sabin Vaccine Institute and Baker Fellow in Disease and Poverty at Rice University.
Ellen Agler is the CEO of The END Fund.