Transcripted by Chowa Nkonde

This is the Challenging Neglect podcast series. I’m Samantha Vanderslott and I’m Erman Sozudogru and we are two PhD students from the Science and Technology Studies department at University College London and today we are joined by Dr. Peter Hotez who is President of the Sabine Vaccine Institute and Founding Dean of the National School of Tropical Medicine at Baylor College of Medicine. As well as his many contributions to the field of Public Health, he has been credited with coining the term “Neglected Tropical Diseases.”

Welcome Dr. Peter Hotez! First of we’d like to hear about your background in Tropical Medicine and how you became interested in Global Health and policy, specifically with NTDs?

PH:      Well, I’ve had a lifelong interest in Neglected Tropical Diseases although they were not originally called that. I’ve had interest in tropical diseases ever since I was in my adolescence, that’s when I knew I wanted to study tropical diseases. I had read Microbe Hunters as a child and that had a big influence and by the time I was 13/14 years old I had a copy of “Tropical Diseases” on my night table. So it’s kind of an odd beginning. As an undergraduate at Yale University where I studied Molecular Biochemistry and Biophysics and worked in a research lab on Human African Trypanosomiasis and then went to the Rockefeller University and Cornell Medical College for their MBPhD program where I began to work on Hookworm infection. So I’ve had a lifelong interest also in trying to develop vaccines for helminth infections (another neglected tropical disease) and that actually began when I was MBPhD student. So I very much started in Tropical Medicine as a Laboratory Investigator with no real intention of becoming a Global Health advocate; that actually happened much later in life.

And what was the motivation behind that, if you can tell us a bit more about that?

PH: So one of the big motivators for going into the policy arena and advocacy was after the launch of the Millennium Development Goals in 2000. So if you remember, in response to Millennium Development Goal #6, there was a call to “Combat HIV/Aids, Malaria and other diseases” and what was clear was that there was an enormous amount of global action in response to MDG#6. This was the policy document that helped launch PEPFAR, the President’s Emergency Plan for AIDS relief. It launched the Global Fund, the Global Fund to fight AIDS and they added TB and Malaria, and this was literally pumping billions of dollars into the system to put people on antiretroviral drugs and other AIDS prevention measures, providing antimalarial drugs and there was really no response to what was called the “the other diseases” and I then realized, at that time, that just by calling something “other diseases” is a way to ensure that there would actually be no global attention. Especially on things like Helminth infections, so it was around this time that I had met up with Professor Alan Fenwick of Imperial College London, David Molyneux of the Liverpool School of Tropical Medicine, as well as Lorenzo Savioli and another very important person there was Eric Otteson, at the time, who was in Atlanta. So we started talking together and meeting regularly either in Washington DC, I was Chair of Microbiology at George Washington University at that time, or Geneva and we realized we had to do something about this. And this is where we formulated the concept of Neglected Tropical Diseases or NTDs, as the term to highlight how a group of these parasitic and related infections has 1) some common features and 2) could be targeted simultaneously with drugs that could be administered together

And do you feel as if you’ve achieved what you wanted to achieve through this coining of this term?

I think we got a good start, I mean we could argue that its maybe not the greatest term in the world, I’m not sure if we could do it all over again we’d call them “neglected tropical diseases” but it seems to have worked and people seem to know what we’re talking about now so we don’t want to mess with a good thing. And so now, I worked very hard on the Washington DC end of things to work with Congress, to get the funds appropriated for these global initiatives; what we initially called them in our two initial papers, “The Rapid Impact Package” to get some work for that. So we had written these two papers for PLOS medicine in 2005 and then in 2006, highlighting the opportunity and mostly the key policy documents that we had worked with US Congress to get these initial funds appropriated.

Is there anything you would have done differently with hindsight?

I mean, you know, people have come up to me in subsequent years and said, “You know, Dr Hotez or Peter, this is the fastest that anyone has ever seen a project move from two scientific publications all the way to policy, advocacy and the actual appropriation in Congress. That’s actually set a record.” By the end of 2006, we had our first funds appropriated, $50 million which is 50 cents a person, which treated 30 million people. So it’s hard to say which things we would have done differently with that kind of track record. I think if we had to do it differently, the only piece that’s kind of dropped off is the research and development agenda. We have been very persuasive at getting funds appropriated through the United States Government and the UK Government for the purposes of mass drug administration. It’s been a bit inflexible in terms of either incorporating additional disease or talking about our programs for research and development for some of the new drugs in diagnostics and vaccines that we be needed to combat these diseases.

I have another question in terms of getting the international collaboration on these things. What sort of medium did you have to talk to different countries and different governments to get them on your side? 

Well, what we’ve done now through the support of the Bill and Melinda Gates Foundation is created an organization that specifically charged with speaking to other governments about mass drug administration and that’s called the global network for neglected tropical diseases and now that organization is working in places Germany, France and other European countries but also looking very seriously at some of the large Middle Eastern countries and we can talk about that separately. A new policy development for me is the paradoxical finding that some of the largest concentrations of neglected tropical diseases are actually occurring in wealthy countries but it’s occurring in the poor living in wealthy countries. So we are finding that more than half of these neglected tropical diseases are now occurring in the G20 countries.

Now this brings us to your Blue Marble Health paper that was published last year. Can you give us more details about that idea so our listeners can know what’s happening at the moment in terms of policy movements in neglected tropical diseases because I think that the traditional conception of neglected tropical diseases is sub-Saharan Africa and parts of Asia and Latin America?

Well I kind of call it NTDs version 2.0, version 1.0 were kind of laid out in the two PLOS medicine papers in 2005 and 2006 about the Lincoln and mass drug administration programs in providing Rapid Impact Packages. I think now things have matured a bit so they can be a bit more nuanced about the whole neglected tropical disease program. I tried to really lay this out in the policy document I wrote last year in PLOS Neglected Tropical Diseases, which had the following elements:

• Hookworm and schistosomiasis are incredibly important diseases; we are not going to eliminate them entirely with mass drug administration. We are going to need additional control to do this, and that’s why we’re committed to developing anti-helminthitic vaccines. Now there’s not by any means a universal agreement within the community. There are some people that believe that elimination is feasible with mass drug administration. I happen not to think that’s going to happen and so there’s some divergence within the community on that.

• I think the other point is that there are some other diseases that we really need to pay attention to. Two of the important ones are the neoplastic diseases particularly leishmaniasis and Chagas disease. So leishmaniasis is now emerging as one of the most horrific consequences of conflict in the modern era, where hundreds of thousands of people have died in places like Sudan and elsewhere as a consequence of Kala-Azar (Visceral leishmaniasis) whilst fleeing the conflict and being exposed to sand flies. Now you have hundreds of thousands of cases of cutaneous leishmaniasis in places such as Syria, Afghanistan as a consequence of conflict and you have almost no global efficacy or attention to that. It’s the same with Chagas disease; we have 8 million people living with Chagas disease predominantly in Latin America and some in the United States. A few of them (1%) have access to essential medicines to Chagas disease, so version 2.0 says “You now have to give some attention to those diseases.”

• And then I think the third component is, now there is while there’s been an enormous amount of rhetoric and some global action on the plight of those women living in poverty, people don’t ordinarily think of neglected tropical diseases as illness of women and I make the point that these are indeed the most common afflictions of those women living in poverty, particularly diseases such as female genital schistosomiasis and hookworm infection during pregnancy and yet there is no global action. One sources of the frustration is that the global health community I feel has gotten very silent and so that the AIDS people don’t talk to the malaria people don’t talk to the NTDs people and yet now there’s evidence that female genital schistosomiasis can be one of the most important cofactors in Africa’s AIDS epidemic, yet there is very little global action or anything about female genital schistosomiasis. Now I brought this to the attention of the leadership of organisations such as PEPFAR and Global Fund, they say they can’t really afford a mission creep. And it’s not really a mission creep; it’s part of the mission. So that’s a really important thing we need to take, so far instance as were speaking, the International AIDS Conference was going on and I could probably almost promise you that no-one will mention female genital schistosomiasis even though it may be the most important co-factor in the Africa’s AIDS epidemic so that’s is a terrible source of frustration.

And then it’s time I get to the concept of Blue Marble Health, which is where we’re finding paradoxically that more that half the neglected diseases are occurring among the G20 countries but they are occurring in areas of poverty in those countries. Places like Southern Mexico or Northern Argentina or Northeastern Brazil or in Indonesia. Here we are actually finding an enormous amount of neglected tropical diseases and these countries have the ability to afford treatments for neglected tropical diseases so it calls on the G20 countries to take responsibility for their own diseases, and, I’ll just say that we are often now finding this hidden burden of neglected tropical diseases right here in the United States and that’s something that needs to be addressed.

Yeah, I’d be really interested to hear your view on how these rising economies might tackle neglected tropical disease differently to the traditional donor-recipient model where developed countries help developing countries.

Certainly for the Rapid Impact Package, the costs are very modest and certainly the India’s, Indonesia’s, the Brazil’s, the Argentina’s of the world could afford to treat their own populations. There just needs to be either program of awareness among the leaders of the importance of these diseases and not only important health problems but also important economic problems and also these nations have the ability to conduct the research and development to take on some of these diseases themselves. It’s a matter of mobilizing ministries of health to priorities these diseases but also the ministries of science to take on research and development. I’ve proposed this; the state department of the United States has recently created their office of Global Health diplomacy and I think this will be a great role for the office of Global Health Diplomacy.

Remaining faithful to the overarching aim of this podcast where we look at different approaches to NTD research, I see that you are very active in the research and development side of things but also you are very active in the global advocacy and global health sections. So can you tell us about how these two sides of career kind of influence each other and how do you see yourself fitting there? Is this a model for people in the tropical diseases field to adopt?

Well I have to tell you, it’s the hardest thing for me to do is to keep afoot in both spheres because to do it well, each is a full-time job. And so this is one of the real challenges I face. To be a global health advocate means that you have to be willing to go on a plane at a moments notice and to attend certain important conferences and workshops and to be educating people in different parts of the world. On the one hand, if you want to stay a working scientist you have to be at lab meetings and stay on top of things in the laboratory and so, I’m constantly feeling an internal tension and this particularly comes up when there’s some important Global Health Summit and I just can’t be away from the lab too long, so even if its something like the London Declaration, when it first happened in London in 2012 and subsequently moved to Paris, I had to make Sophie’s Choice. Do I go to that and then jeopardize some key aspects that are happening in the laboratory or not and ultimately I chose to stay at home and be in the lab and so they are not easy things to do. But I do think it’s important as a scientist that you communicate to the public and this is something that I’ve been pushing very hard on young scientists. We have a little crisis of science in the United States and actually globally and people don’t necessarily think we need science and I have been really telling young scientists that this is part of their obligation to work for the public and engage the public.

Have you found that young scientists are equipped enough or have the drive to become involved in policy in the way that you have been?

Not everyone but there are many who are, so I found that the commitment to public service amongst young people is at an all time high. So they want to do it but they also recognize that they maintain a day job in science and they have to stay fixed on things like grants and papers and those kinds of things, so it’s not always easy to make time for it. At their level, the consequences of not doing it are high, I’d like to quote a recent study about a policy group in Washington DC called “Research America” that was just completed, where they found that 70% of Americans cannot name a living scientist and that study went on to show that a significant percentage of the American population believes that Albert Einstein is still active. The most recognized living scientist in the United States in Stephen Hawking and the second is Bill Nye the Science Guy. So clearly there is an enormous level of scientific illiteracy in the United States and then the study went on to show that 60% of Americans couldn’t name an institution where biomedical research is conducted and only 9% have ever heard of the NIH. And so you wonder why we have flat-lined funding in science the last 15 years and so that the amount of funding available now is now 5% less than it was less than a decade ago and I say well that’s probably our fault because we’ve not taken the time to educate the population about why we need science and scientists.

That’s a very interesting point because there is an ongoing debate in Science and Technology Studies about the ways to communicate with the public and it’s very interesting to hear a scientists view in a different context. I’d say you think there needs to be very loud advocacy from the NTD sphere in order to get people behind this project that you set up 10 years ago. Would you agree with that?

I think we’ve done a pretty good job now about getting and making people aware of the opportunity for the Rapid Impact Package with the low cost means to treating and sometime in the future eliminating diseases. The hard part now is selling people on the idea that we have diseases that may not be affected by the Rapid Impact Package which need attention like leishmaniasis and Chagas disease. And we also have to be careful not to oversell the Rapid Impact Packages on what it’s going to do. It’s not going to eliminate schistosomiasis, its not going to eliminate the pests of the helminths because that would then need additional tools. We are going to have to do other things as well and that’s been a tough sell. The toughest sell of all has been the idea that countries like the United States have extreme poverty and with it a large amount of neglected tropical diseases. I’ve been really struggling with getting information out about that concept and why we have to care about poor people in their own country.

And is it the public awareness part, is that where you’re concentrating your efforts at the moment because you’ve talked about involving Congress and the rest of the community.

Well what we’ve done is a few things. First of all we’ve actually moved we’ve moved to Houston, Texas, which is Ground Zero for the United States of Neglected Tropical Disease problem. There is the National School of Tropical Medicine, the Baylor College of Medicine and what we’re doing is we’re developing a vaccine and diagnostics for these neglected tropical diseases but we’re also trying to now conduct epidemiological studies of these diseases right here at home and the soundbite of the school is “We aspire to be like the London School of Hygiene and Tropical Medicine and Liverpool School,” with the difference being we’re in a disease endemic area in the Gulf Coast of Texas which is one of the ten global hotspots for neglected tropical diseases.

I’d like to hear a bit more about the National School of Tropical Medicine and how it might differ from the historical schools, Liverpool and London and in Europe.

So it has some similarities in that both schools have a 100-year track record of conducting trans-relational research and certainly we’re doing that. Also, one of the ways in which we diverge is we actually have a product development partnership in our school and that’s the Sabine Vaccine Institute that’s making neglected tropical disease vaccines. I think the other component I we’re trying to have particular attention to the problems here in the Western Hemisphere, which is probably areas that are less, emphasized in some of the European Schools of Tropical Diseases and the fact that we actually consider ourselves actually located in a disease endemic area. I’ve come to visit the Texas Medical Centre many times before actually moving. The Medical City of 100,00 employees is the world’s largest medical centre and I’ve often thought, “wouldn’t it be amazing to be able to harness this medical centre to solving problems of developed countries?” And now we have that opportunity and so we’re actually really trying to conduct observations, epidemiological studies and molecular epidemiological studies on the diseases we have here at home.

Okay so it sounds like your thinking about where the future of NTDs will be and that’s something that’s been taken into account in the school of tropical medicine there.

That’s right and we have a policy component to that of course as well as of the Blue Marble Health, that’s coming out of the school and there are some other ideas.

So can you tell us what your view is on the future of NTDs, let’s say in 2020? What our conversation would entail?

I think that conversation is going to entail one focusing on elimination targets and what we’re going to need for that. I think that we’re going to see that the most of the neglected tropical diseases will go a long way with mass drug administration but it’s going to face some disappointments when it comes to elimination and I think that’s why we have to start putting in place now. Our mission is to develop new control tools, even though it will be expensive, I think it will be worthwhile, that’s going to be very important. New vaccines, new diagnostics, new drugs, there has to be a greater urge in support and interest in making that happen. I also think we need to mobilize other parts of the global health community, so that people do not see neglected tropical diseases as a silent problem and to be recognized as the leading health conditions in those women living in poverty and not think the NTD community will be successful without the involvement of PEPFAR and the Global Fund and then those two organizations need to be better engaged. And then, we’re looking at the whole concept of science diplomacy and that has to happen on two different levels. First, the G20 countries need to have greater involvement and right now most of the support for the burden of neglected tropical diseases is coming from the US and UK governments. We need to involve all the G20 countries both the high-income and middle-income countries to take care of their own countries but also do more for places like Africa. An example is China, the government in China investing billions of dollars in sub-Saharan Africa but not a penny for neglected tropical disease control. That’s got to change if we’re going to be successful.

I think that’s actually a good point to end with because there’s been a lot achieved but still an urgency to make moves in some areas. Thank you very much for sparing some time for us Professor Hotez, it was a pleasure to talk to you.