This is the Challenging Neglect podcast series. I’m Samantha Vanderslott and I’m Erman Sozudogru. We are two PhD students from the Science and Technology Studies Department, UCL. Today we’re interviewing Professor Alan Fenwick who’s Professor of Tropical Parasitology at Imperial College in the UK. He’s also Director of the Schistosomiasis Control Initiative (SCI) and he’s worked extensively, not just on research, but actual control of NTDs in Africa, so welcome Professor Alan Fenwick. Okay. Thank you. It’s a pleasure. Can we start by talking a bit about your background in Parasitology and Epidemiology and how you became interested in neglected tropical diseases specifically just to set the scene? It does go back rather a long way, but yes I started life actually as a chemist and in those days, 50 odds years ago, anyone who finished their first Honours Degree could go on and do a PhD, funding was available a lot easier than today, but one needed a topic and I was wanting to do something a little bit out of the ordinary and my supervisor suggested that I go to the School of Tropical Medicine because they had got some funding for looking at the chemistry of water and how copper salts would kill snails, and this seemed liked a very interesting project and I took it on.
However, I soon became much more interested in why they would want to kill snails and, of course, it was because snails transmit Schistosomiasis, so I got more and more interested in the parasite than in the actual killing of the snails. And, added to that, I very quickly was able to work out that copper sulphate would not actually work in the field in Africa because it was very quickly precipitated by the alkaline and dirty muddy waters there and then was not available to the snails. So you put the copper sulphate in and it would disappear before it killed anything. So that left me in a bit of a quandary because that didn’t take that long and it certainly wasn’t going to be enough for a PhD project. So I agreed with the powers that be at the School of Topical Medicine that I would take a number of different courses on Parasitology and they would give me a Masters Degree and then honour would be satisfied, I would leave with a Masters Degree, we would tell the Copper Development Association that their money was wasted and the School, you know, wouldn’t be kicking out a PhD student with nothing to go for. And so basically I was the first ever Masters Degree in Parasitology and now you may know that the Liverpool School and the London School all have Masters Degrees in Parasitology but there were none at the time. I had the honour of being the first ever one and I did my dissertation on snails in ponds in the UK and the trematode parasites that they had inside them. I was very lucky because at the end of that year I was conferred with this Masters Degree and the Professor of Parasitology called me in and he said, Alan, you must be wondering what’s going to happen to you now. Well, look at this, and there was an advertisement in Nature from the British Government saying that they wanted a biologist with an interest in chemistry to go and kill snails in Tanzania and, of course, I was a chemist with an interest in biology and there weren’t many people around at that time, so I got the job and I was sent off with a five year contract to go and work in Tanzania as a research scientist, and as a result of that five years I got my PhD from the School of Tropical Medicine and became a full blown parasitologist with a specialist knowledge of Schistosomiasis. That’s very interesting to hear because my initial degree was in Biological Chemistry which is… you can do an undergraduate degree in that now. Well, if only you’d been around in 1966, you could have challenged me for my job! Yes. So then I was very lucky, I was an ex-patriate in Tanzania and in addition to training some Tanzanians, I was also able to do a lot of diversified research on Schistosomiasis and published a number of papers which led to a relatively easy passage to a PhD. From there I was headhunted to go to the Sudan because the London School of Hygiene and Tropical Medicine had just had two students from the Sudan who had graduated with PhDs and they were going to go back to the Sudan, and in those days there was an opportunity from the Wellcome Trust for them to go back with a grant so that they weren’t just going to disappear into what were very difficult working conditions in the Sudan, but that they would have some research funding. And my mentor at the London School, Professor George Nelson, who was a very senior professor at that time, he came up with the idea of instead of just sending them back with this money why don’t we send this idiot as well and he can work with them and my job was to make sure that they succeeded. So I went to Sudan and I stayed there for 17 years, set up a research project, the Blue Nile Health Project for controlling Schistosomiasis, Malaria and other diseases, and one of the two guys became the Minister of Health, so I guess I sort of was successful. What year is this roughly? I went there in 1971 and stayed there until 1988 and then 1988 I moved down the Nile to Egypt where I was the Chief of Party on a USAID funded project to do research and train Egyptians using the American money. It was a ten year project but I managed to extend it to 14 years and, at the same time, the World Bank gave a large grant to the Ministry of Health to actually control Schistosomiasis. The new drug Praziquantel came through at that time and over a 14 year period we delivered over 70 million doses of Praziquantel to school age children and reduced the prevalence of Schistosomiasis from about 60% to 5% in Egypt. And that was the stepping stone for SCI because prior to the year 2000 there wasn’t a single Schistosomiasis control programme in sub-Saharan Africa and the Gates Foundation gave us funding to actually start work in six countries and over the last 12 years we were fully supported here at Imperial College with SCI by the Gates Foundation for seven or eight of those years and then we got funding from the American Government, and now from the British Government, and from various other donors so that we can go forward with our implementation. Can I ask you… so you said you were working with the locals in these countries that you lived in and doing training? So what sort of research was going on and what did this training entail? So what was the nature of..? Yes, in Sudan I was affiliated to the Ministry of Health and the University and I was able to supervise a number of Masters students and PhD students at all levels. One of them looked at the economic benefit of treating Schistosomiasis, somebody else looked at the quality and the distribution of different drugs because at that time Praziquantel was only being tested and there were one or two other drugs that were in the pipeline, although they didn’t actually go through. There was one called Altapraz [?] and there was another drug called Neridosol [?] and, you know, as we treated more and more people with them, we realised their shortcomings and Praziquantel came through as the best one. Somebody else worked on molluscicides to kill snails and there were two competing molluscicides at that time. One was Niclosamide and the other was N-trityl-morpholine. N-trityl-morpholine turned out not to be good enough. Niclosamide was good enough. It was very effective in killing snails but unfortunately it also killed other aquatic organisms which meant that it was environmentally relatively unacceptable and the other thing was that it was a product which went up in price. In the 70s and 80s the price of petrol rocketed and this was, you know, a derivative of the oil industry and so it just became too expensive to use. So we were left with one bullet in the gun which was Praziquantel. And who was conducting this drug research? So where were these drugs developed? The Praziquantel was developed by a combination of Merck and Bayer Okay. This is Merck KGaA? Yes. And what they did was, they sort of divided the world geographically and so one company would sell in one part of the world and one in the other, and then in about… I would guess about 1995, something like that, a South Korean company called Shin Poong patented a different… an analytical method for producing Praziquantel and they dropped the price hugely and so Praziquantel from being basically unaffordable because of the large numbers of people who needed it… Bayer were selling it for $1 a tablet originally, and the only people who bought it were the German Government basically who then donated it to one or two of the countries but it was not sustainable. Shin Poong came out and the price dropped by 90% which made it suddenly not too expensive. I could buy… I was buying… in my latter days in Egypt and then subsequently when I came here, I was buying a dose which would cure a child for 20 cents, which is, you know… admittedly we needed a lot of it, but for the next ten years Praziquantel was the bottle neck. Now you’ve obviously done your homework and you know that Merck KGaA are going to donate an increasing amount of Praziquantel as the years go by. They started with 20 million tablets, which is enough to treat 8 million children. By 2016 they will be donating 250 million tablets which is enough to treat 100 million kids. How the hell we’re going to treat 100 million children in any one year I don’t know. We’re going to have to really rack up our delivery system. At the moment we’re treating 30 to 35 million a year. Yes. What I want to ask now, so your role as an epidemiologist working in… very close in context where this disease is prevalent, what was your feedback to these companies? What was your interaction with them and how did you feed back your knowledge and contacts? Well, in the 1990s when I was in Egypt the interaction was purely and simply financial because the money to buy the Praziquantel was coming from the World Bank and the World Bank had a procurement system and a tender system whereby it was price and quality related, and Shin Poong’s quality was every bit as good as Bayer’s, and so basically we said to Bayer unless you drop your price, nobody’s going to buy your drug. And that is what has happened. Virtually nobody buys Praziquantel from Bayer for human consumption now. They still make the active ingredient and they sell it for animal deworming but my feeling is that virtually nobody buys the Bayer drug anymore. Shin Poong then cornered the market for a while, but the market wasn’t very large because there wasn’t the money to deliver the drugs and the countries themselves didn’t prioritise Schistosomiasis as a disease which needed treatment. So it wasn’t until the Gates Foundation gave us a grant, which was about $30 million in 2002, that there was actually any national programmes in sub-Saharan Africa. We started in six countries in 2003. By 2006 we’d added two more countries to make it eight and currently we’re in 16 countries. It sounds like you were quite active on the ground. Do you think that’s something other parasitologists look to do? I think the generation of people living in Africa as ex-patriate parasitologists has gone for a number of reasons. One is that the number of universities in sub-Saharan African countries has mushroomed. When I was in the Sudan, there were two universities. I think there’s 40 now. You know, it really is huge. Don’t quote me on those particular figures. And the same in Eygpt, there are private universities, every town and every city has its own university, so that means there’s many, many more people qualifying. And in each one of these countries the prestigious subject to study is medicine and many of the people in tropical countries have tropical diseases as their speciality. So there is no longer the opening… you know, a lot of Masters degree students say, oh, I love what we’re doing, can we volunteer, can be go out to the countries to research, but actually the truth is that they’re not as welcome as when I first went there because there was nobody there when I first went. But today there are parasitologists, there are doctors, there are biologists who have graduated from their own universities and so anybody coming from the UK to some extent is taking their place, which is not really as easy as it was in my days. So how would… what would you comment about the public/private partnerships like the NDI’s effort? The NDI is a completely different animal to what SCI and RTI and CNTD… they are the three organisations which deliver these donated drugs with money from USAID and from the British Government. The NDI is upstream. They are looking for new drugs, so they’re not looking for drugs for Schistosomiasis because we have a drug for Schistosomiasis and it’s almost a miracle drug, to be honest with you. And it’s the same with the deworming drug. We would like a better drug, we would like a backup drug in case resistance develops, but the truth is even if we got one, no one’s going to be able to sell it. So there’s not really much of an incentive for a pharmaceutical company to develop a drug that they’re not going to be able to sell and they’re going to have to donate it. The NDI on the other hand are focussing on… with grant money, on diseases for which there isn’t a drug or there isn’t a good drug – Leishmaniasis, Chagas Disease and Human African Trypanosomiasis. So they are very much complementary to what we do. I mean, in the year 2000 Malaria, HIV and TB were the neglected tropical diseases. They are no longer neglected. Because of the President’s Malaria Initiative, PETFAR, and the Global Fund, they have all the money that they… well, they probably don’t have all the money they need, but they have a helluva lot. You know, we’re talking billions, whereas the amount of money available for the control of neglected tropical diseases is in the hundreds of thousands or the hundreds of millions instead of billions. So times have changed and then for a period when we talk about neglected tropical diseases, we talk about the seven diseases which are susceptible to mass drug administration, for which we have these drugs. The others are what you might call even more neglected topical diseases and the next level, if you like, is HAT and Chagas and Leishmaniasis. But the number of people who are infected with those compared to Lymphatic Filariasis and Onchocerciasis and Schistosomiasis and particularly the intestinal helminths is relatively few. And then behind that you’ve got the even more neglected tropical diseases of which there is one exception, and that’s the one which is expanding, and that’s Dengue. But all the others are partly being controlled by all these donated drugs almost accidentally. So things like… diseases like Scabies have disappeared because people have been taking systemic deworming tablets like Mectizan and Albendazole, and almost incidentally Scabies has disappeared. Now when we’ve got rid of Onchocerciasis and Lymphatic Filariasis, which is targeted by 2020, what’s going to happen to the other parasitic diseases because they were never targeted for treatment and the treatment that is being given for those more serious diseases is going to stop? So that’s an interesting parasitological question which is going to come up in the future. I’d really like to hear what’s your definition of neglected disease. Well, as I in a way pointed out, the definition has changed as years have gone by so that in the year 2000 neglected tropical diseases didn’t include Schistosomiasis. They were even more neglected. The word… the phrase neglected tropical diseases was only coined in 2003/2004. The World Health Organisation convened a meeting in Berlin which I was at and we… it was a mixture of people who were interested in the various diseases and a selection of African Ministers of Health and whatnot, and we sat down and we talked, and we said what are we going to do? We’re starting with Gates’ money to treat, so there was a group who were treating Trachoma, there was a group who were treating Onchocerciasis, a group who were treating Lymphatic Filariasis, and we were doing the Schistosomiasis and intestinal helminths. But as we were expanding our coverage we were knocking on the same door. And so the big question came up, can we integrate what we’re doing and who the hell can pronounce all these names? I’m the only one who can pronounce all these names and spell them. And so we needed a collective phrase and we discussed a number of different phrases and neglected topical diseases was the one that was selected, NTDs. Of course they’re not as neglected now as they were ten years ago. There is now half a billion dollars coming through from USAID and a quarter of a billion pounds sterling from DFID, so there’s almost a billion dollars coming through over the next five years, and that’s probably a third or a quarter of all that’s needed between now and 2020 to actually eliminate these diseases if [unclear] administration will do it. Now there is a great argument that says that [unclear] administration isn’t enough and I can’t disagree with that. However, from the policy point of view if anybody has Schistosomiasis, and 200 million people have, putting in water and sanitation isn’t going to help them. The only way to cure people who are currently infected is to given them Praziquantel; the same with deworming, the same with Onchocerciasis. People who are going blind, unless we treat them, they’re not going to get better. The same with Lymphatic Filariasis, unless we treat them, they’re not going to stop the transmission. Having given them all the treatment we can then save on retreating by stopping transmission by giving them water and sanitation, but step one is to deal with the individuals who are currently suffering. Do you see a trade-off between those sort of short term and long term measures? I think undoubtedly there is a short term trade off but I think that… I firmly believe that attendance at school, for instance, has been encouraged by governments but I don’t think that it would have happened if we hadn’t been treating all these diseases because kids feel better now. If you think about it, when children reach the age of five, they’ve survived all the childhood diseases that could have been thrown at them. Admittedly there’s a lot of vaccination going on, but they haven’t died of polio, they haven’t died of measles, they haven’t died of malaria, they haven’t died of congenital HIV. They should be as healthy as they’re going to be at the age of five. They’ve developed resistance to chickenpox and all these other childhood diseases. The only thing that hits them are these parasites. We don’t have them in the UK and I’d like to suggest to you that that’s why everybody’s child is a foot taller than their parents because of nutrition and because of the fact that these parasitic diseases have disappeared from the UK and from Europe and from America. Kids are much better nourished now. Now in Africa they are still infected and almost every rural child has one or more of these parasites inside them. Once we treat those kids then they should have a healthy and top education between the age of five and 13 when perhaps they become sexually active and then HIV is the big threat for them. But the parasites thrive in that age group of children and so this is what our job is, is to get the drugs out to those children during that period so that they can benefit from school. Now if girls go to school, they are a lot less likely to get married at a young age, they’re a lot less likely to be susceptible to HIV, so schooling is really critical and that’s what we’re trying to do. But how do you deal with the differences from one country to another? Every country has its own Ministry of Health, every country has its own staff and the staff have all been taught by usually parasitologists in Europe and in America and they will have taken home slightly different messages. What we do is a country programme. We give ownership to the country, but if they’re not doing what we really think is the best, we try and persuade them to do it a little bit differently, but in the end the countries have a choice. They can either do school based deworming and treatment which is, let’s face it, easy because you’ve got a captive population, they will do what the teachers tell them. If they’re lined up and the teachers say, you know, we’re going to give you pills today, they’ll take the pills. But the school age children and the school attending children are only a small part, particularly in rural Africa where school attendance can be as low as 50%, and the 50% who aren’t at school are probably indulging in activities which will lead to them getting re-infected with these diseases. So it’s really important to reach out to non-school attenders. And then because these programmes are so new, what about the kids who left school last year or the year before? So the adolescent population also need reaching out to. And then because most of these diseases are either vector borne or water borne, you’ve got to work to try and reach out to adult populations who are particularly involved with at risk occupations. The obvious ones are fisherman, agricultural workers, and we also need to reach out to women of childbearing age because all of these parasitic diseases cause anaemia and the greatest threat to a satisfactory birth outcome is if the mother’s anaemic. So it’s really important that we reach out and treat women who are either pregnant or of childbearing age. It sounds like what you’re saying fits into a broader development agenda. Is that something you’ve been seeing more in your work? I would say so and I think in fact what we have used in our arguments when we’ve gone out for support is, first of all, we have the drugs, so the drugs are effective and they’re relatively safe. SCI has treated 100 million people since we started, over 100 million people. We have had two or three children who’ve died after treatment, but in every case the parents brought them for treatment because the child was sick. They shouldn’t have been treated with Praziquantel. They probably needed an anti-malarial and because they were treated with a pill, the parents thought, oh, my child’s been treated and then the child died. So Praziquantel… I honestly would put my hand on my heart and say Praziquantel has never killed anyone. So they’re safe. And then the thing is that, you know, they were inexpensive and they’re now free, and they don’t do any harm, they can only do good, so I believe that the delivery of these drugs is a benefit to society and a benefit to children who would not otherwise receive any treatment. We use the millennium development goals as an argument. Think of the millennium development goals: reduction in poverty, how are you going to reduce poverty if people have got these diseases which are debilitating; improved primary education, how are you going to improve primary education if kids have got parasitic diseases which make them too tired, suffering from malnutrition and not able to either reach school or fall asleep when they’re there? How are you going to improve birth outcomes if women are anaemic whereas if we treat these women they will cease to be anaemic because we’ve got rid of the cause of the anaemia and birth outcomes will improve? So, you know, three of the eight millennium development goals are immediately totally dependent on there not being these neglected tropical diseases. I’ve found what you’ve said really interesting because it’s very evident that the whole context, as you’re saying, and our aims and goals in terms of eradicating these diseases, have a major impact on the research that’s being done in the field and I’m more interested in the dialogue that goes on this. So who… people who do this research and look at… you know, and sets these goals, the millennium goals, how do they then infiltrate into scientific research? I think, I think a lot of it is individual dynamism and drive. I mean, you’re in an academic arena here. People like yourselves want to get a PhD. Now when I was doing the PhD, it was dead simple because nobody had done any of this stuff before but how do you find the subject for a PhD which is unique today when how many PhDs have been written in the last 50 years? You know, you could say it’s very difficult to find something new. So we have a number of Masters students and PhD students who are looking to find the niche which has not yet been filled. It’s very exciting because the other thing about these, I call them, young kids because they are compared to me, and so are you, but these young individuals is how enthusiastic they are and how incredibly bright they are. It’s a fantastic whole field related to the millennium development goals of people who are looking to find something unique to do and parasitology because it’s been neglected for so long does offer research applications to people who are looking to do something in the biological sciences. Just to clarify for the listeners who wouldn’t have necessarily grasped the idea of a parasite that kills its host is stupid? Well, yes, because, for instance, Schistosomiasis lives inside the blood of the human body. Now if that human dies, the worm’s going to die because the worm is dependent on the human surviving. Now, in the old days, if you like, in the days of the ancient Egyptians there were snails living in the Nile and every year there was a flood and the snails were washed away and they had to repopulation. The population of Egypt was probably 3 million compared to 100 million today and therefore there weren’t that many people who were bathing in the Nile and getting infected, and so the parasite Schistosomiasis has a really hard time in finding its various hosts and it did it by, A, the adult worm laying millions and millions of eggs and, B, the snails releasing many, many parasite larvae which could infect the human being. Now the face of Egypt has completed changed today. The Nile delta is no longer flooded annually because the Aswan Dam blocks the flood of the Nile and so the snails aren’t washed away. They therefore proliferate and the population of Egypt, as I said, has multiplied and so the sanitation leads to many more people defecating in the rivers and urinating in the rivers, so many many more snails can get infected and the parasite has found… or did find the most perfect situation to proliferate. So 50 years ago before any control measure the Schistosomiasis in Egypt was the most important disease. I think that would be a great note to finish on, so these neglected diseases they’ve been an ancient problem but what do you see now for the future? Well, what the World Health Organisation has set as a target and the Ministers of Health of every developing country has signed up to this is to try to eliminate the top ten neglected tropical diseases by 2020. Now they won’t do it, but they’re working towards it. The pharmaceutical companies have bought into it and they have entered with their corporate responsibility vast donations. I mentioned 250 million tablets of Praziquantel every year from 2016 to 2020. GSK are donating a billion tablets of Albendazole every year from now until 2020 to get rid of both intestinal worms and Lymphatic Filariasis. Merck in America are donating millions of tablets every year of… hundreds of millions of Mectizan which is used for river blindness and for Lymphatic Filariasis. There are other companies as well which are donating, Pfizer for Trachoma, Eisai which is a Japanese company is donating DEC, Novartis is donating drugs against Leprosy. These diseases are being hard hit and the drugs are available. What we’ve got to do is to get the drugs out. The big problems for us now are Ethiopia, the DRC and Nigeria because those three countries alone probably contribute 50% of the people in Africa who are infected and yet, as you know, the governments and the health systems in those countries is a bit fragmented. Ethiopia is very much on board now and they will be the next country that has full national coverage but Nigeria and the DRC, I mean obviously, you know, the governments in those countries are suffering a little bit. And as soon as you get civil war and you get civil unrest, the first thing that suffers is the health system. So that’s something we’ve got to overcome. Thank you very much.