By Marty Logan
MONTREAL, Apr 6 2004 (IPS)

When two U.S. Special Forces soldiers back from Afghanistan reported to hospital late last year with symptoms that suggested visceral leishmaniasis, known in India as kala-azar or black fever, doctors tested their bone marrow for the disease, but the results came back negative.

Two months later, more testing using light microscopy finally discovered the leishmaniasis parasites that were causing the soldiers’ fever and weight loss.

One was treated with drugs for a week and stabilised while the same treatment failed for the other soldier, who was re-hospitalised, and last month started a 28-day course of another drug, according to the U.S. Centres for Disease Control.

But for most of the half-million people – mainly in Asia and East Africa – who contract kala-azar annually, treatment is not nearly so intensive.

"Today if you have no limitations, probably you can manage a case," says Bernard Pécoul, of the Drugs for Neglected Diseases Initiative (DNDI). But amphotericin B, the drug initially used to treat the soldiers, has one form, which is a modern drug, "very active but extremely expensive and very difficult to use," he explains.

"If you are in a hospital in Washington or in Geneva you can use this very sophisticated treatment, but unfortunately for people affected in the northern part of India or the eastern part of Africa, you need something much more adapted to the conditions and at a reasonable price," he adds.

Launched by Médecins Sans Frontières (Doctors Without Borders) in 2003, DNDI has now spun off into an independent entity so that it can focus on science, which is not MSF’s specialty, says Pécoul – who worked for the organisation for 20 years – in an interview from Geneva on the eve of World Health Day, Apr. 7.

He says the new programme was born from the observations of MSF staff in the field, who saw medical personnel in developing countries treating diseases with old and sometimes dangerous remedies.

With no obvious financial return, private pharmaceutical companies were unwilling to spend millions to develop new drugs to fight the diseases.

"The obvious reason is the failure of the market, but I think we need to add a very important second rationale – the failure of the public health system. Classically when the market’s not working, the governments need to (step in) but unfortunately for these populations, no one was compensating," says Pécoul.

"Since the end of the colonial period, research and development for tropical diseases has been totally abandoned."

For example, African trypanosomiasis (sleeping sickness) is still widely treated with a drug derived from arsenic, developed at the end of the 19th century, says Pécoul. Doctors know that it is likely to kill one in 20 patients. "It’s very difficult to accept that you use drugs with such level of toxicity," he says.

American trypanosomiasis, or Chagas disease, is the third sickness being targeted by the DNDI. A widespread parasitic illness, it kills an estimated 50,000 people annually in the Americas.

The three diseases affect about 350 million people a year.

A study by the Washington-based Population Reference Bureau, released in February, found that only 13 of the 1,233 drugs (slightly more than one percent) that reached the global market between 1995 and 1997 were for tropical infectious diseases.

DNDI developed a two-pronged approach to its challenge: to call for proposals from researchers on developing new treatments, and to find partners already working in these areas.

Pécoul says the first strategy has produced hundreds of proposals from researchers, and work is under way on nine projects, with staggered dates of completion. Two should result in new drugs within a decade, while others are scheduled to produce results in a couple of years.

Next year DNDI hopes to unveil two new treatments for malaria using combinations of existing drugs, a project started by MSF in 2002. "It will make a difference for the people because it will be a very effective treatment, very simple, at a reasonable price," Pécoul says.

New drugs for kala-azar should follow, but "definitely the situation is much more difficult for sleeping sickness because the field has been more abandoned," he adds.

One observer suggests that DNDI, whose efforts are laudable, should not be a global health priority.

"The neglected disease initiative is important but it strikes me that getting everyone who needs ARVs (antiretrovirals for HIV/AIDS treatment), tuberculosis treatment and malaria prophylaxis should be the beginning," says Anne-Emanuelle Birn, who holds the Canada research chair in international health at the University of Toronto.

"We already have these medicines available and the mortality from these diseases together is about six million people a year," she explains.

In any case, drug treatment is only one element of improving health in the developing South, she adds.

"International health efforts need to be integrated with public health and social prevention efforts," including improved health infrastructure, sanitation, material conditions, and a decrease in inequality, said Birn in an e-mail interview.

"Otherwise we squeeze one side of the balloon and another problem emerges elsewhere," she said.

Pécoul says DNDI does emphasise the public role in providing health care. "At the end of the day we consider that it’s a public government responsibility to deal with research and development for the most neglected people, so it was very important for us to include public research institutions in this project."

"A lot of (partners) are coming from the public sector, representing the government of India, the government of Brazil, the governments of African countries – so it was really a political objective."

While not ignoring the world’s drug-makers, Pécoul says they will play a small part in the initiative.

"Definitely they will have to play a role, not a leadership role because we are not confident that this type of disease will be at the top of their agenda, but because they have a lot of potential and expertise."

In particular, he says private companies own libraries of compounds that would be useful to DNDI’s research. "We’ll try to convince pharmaceutical companies to give us access… We are not asking for money; we are asking for access to some molecules that they are not using at all – they are just protecting their potential interests."

Obtaining access to that material is just one of the challenges in translating MSF’s very vocal critiques of the global health system into concrete results, notes Pécoul.

"It’s difficult, but at the same time we’ve confirmed something – there is still a lot of progress being made on the scientific side. Even on this kind of very abandoned disease, within the universities there is more and more knowledge."

"The problem is that this knowledge is not translated into knowledge for the people. There is a major gap," he adds.

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