Poverty Trap in Sub-sahara Africa: The Case of Neglected Tropical Diseases (NTDs)

Introduction

Sub-Saharan Africa (SSA) remains one of the most impoverished regions globally, seemingly trapped in poverty or just emerging from it. Fighting poverty and minimizing unjust inequalities are top priorities in developing countries (1). African countries have made much effort to reduce the evolution of extreme poverty, to provide a better life for their population. This includes ensuring the health of the population, a fundamental aspect of building the foundation of economies to escape poverty. Health and poverty are inextricably linked and interact in many ways, undermining human capabilities, possibilities and opportunities (2). Permitting poor populations to be in good health to carry out their economic activities will go a long way in reducing the burden of poverty on them. Unfortunately, some diseases specifically target poor populations due to limited access to clean water and poor sanitation. These diseases are referred to as neglected tropical diseases (NTDs). NTDs are a diverse group of ancient conditions, numbering 20, that have plagued humanity for centuries (3). They are mainly prevalent in tropical areas, affect impoverished communities, disappear as living conditions and hygiene improve and cause devastating health, social and economic consequences to more than one billion people all over the world. Africa accounts for nearly 40% of the global burden (3, 4). Thus, fighting against these diseases will be a building block to eliminate poverty.

Africa is known for being one of the least developed and poorest continents and NTDs are the most prevalent illnesses afflicting the 500 million poorest people in SSA. Taken together, they result in a disease burden that may be as high as half of SSA’s malaria disease burden and more than twice that of tuberculosis (5). As NTDs are particularly prevalent in the continent, this paper thus aims to discuss the dual relationship existing between poverty and NTDs and to present global efforts toward mitigating the disease, the challenges and actionable recommendations to curb the economic burden of these diseases on the population in sub-Saharan Africa, hence contributing poverty alleviation.

How do NTDs make poor people poorer?

Poor health has a direct and indirect effect on individuals and the economy. The working capacity of an individual affected by a disease is reduced as is the case of NTDs affected individuals. NTDs are mainly prevalent among impoverished communities in tropical areas due to poor hygiene and sanitation, and it is often challenging for these populations to access health services as a result of limited health facilities (6). Even with successful access to health services, they may face financial barriers. Lack of health insurance coverage in many sub-Saharan African countries forces households to pay for healthcare services out of pocket, leading to considerable financial strain and even financial ruin, resulting in delayed treatment, missed diagnoses, and poor health outcomes; further contributing to poverty (7). In addition, failure to obtain treatment can lead to death which reduces the economic output and manpower of a country. In the African context, this will lead to the organization of a burial ceremony which further impoverishes the family and thus contributes to accentuating poverty in the community.

What steps have already been taken?

In the early stages of the advocacy for the fight against NTD, the WHO has focused on the need to scale up medical interventions. To that effect, the GlaxoSmithKline (GSK) donation of albendazole for the preventive treatment of lymphatic filariasis in 1997 marked the first contribution through WHO. Since then, the number and volumes of medicine donations for NTDs have steadily increased (8). By 2011, the creative approach and the medication donations had not significantly advanced the implementation process. To improve NTD prevention, control, elimination, and eradication by 2020, WHO published an NTD roadmap on January 30, 2012 (9). To date, a new roadmap (2021-2030) has been launched aligned on five strategic public interventions which are; innovative and intensified disease management, preventive chemotherapy, vector control, veterinary public health, and provision of safe water, sanitation and hygiene (10).

The implementation of these roadmaps has greatly contributed to the fight against these diseases. In 2021, 1.65 billion people were reported to require mass or individual treatment and care for NTDs, down from 2.19 billion in 2010, a reduction of 25%. Furthermore, by 2022, 47 countries had eliminated at least one NTD, and more countries were in the process of achieving elimination(11). In the African region, 19 countries had eliminated at least one NTD (11). Despite this progress, Africa alone represents over one-third of the global burden of NTDs and represents the second most affected region with 584 million inhabitants requiring intervention (11).

The epidemiology of NTDs is complex as it involves many environmental conditions. Many of these diseases are vector-borne and have animal reservoirs with complex life cycles (4). All these factors make their public health control challenging. Efforts to combat NTDs in Africa have seen accelerated international initiatives, with coordinated efforts from governments, health and development groups, donors, and commercial firms. However, there still exists a significant gap in the fight against NTDs.

Why are NTDs still a burden in sub-Saharan Africa?

The word “neglected” in NTDs is attributed to the fact that historically, they have not received as much attention as other diseases. Even developing countries who are endemic for these diseases and who strive to move out of poverty disdain them. This leads to a reduced allocation of financial means to tackle the disease (13). A logical consequence of such a disregard is that research in the domain of NTDs is relatively scarce. Since the disease targets poor populations, big laboratory firms will not be desirable to engage in such research as there will not be a good market for their product. This is the case of dracunculiasis, which to date has no medical treatment, and for Buruli ulcers with expensive and long-lasting treatment.

It is also important to note the under-use of advanced and big data analytical technologies. As a result, the implementation of a clear and elaborate surveillance system is lagging. Such a situation will eventually lead to under-reporting of the disease and an incapacity to map the distribution of the disease to target interventions (14).

Another challenge is the lack of knowledge among the populations (15,16) and even health care workers on the disease. In SSA, populations have a superstitious perception of NTDs, affecting their willingness to seek help from health facilities (17). Even when they accept the germ theory (18) and decide to seek health services, they may not have a health facility in the locality or accessibility to health services since these diseases mostly afflict people in rural areas. Some studies have also reported that some health personnel do not have adequate knowledge of these diseases (19). This affects the quality of care offered to patients who present for care.

Hygiene and sanitation are the greatest risk factors for these diseases. In some sub-Saharan African countries, especially in remote areas, there are still promiscuous water provision sites with sanitation not being the best. As evidence, a WHO report reveals that 2 billion people worldwide still lack access to basic sanitation, with 7 out of 10 of these individuals living in rural regions and a third in least developed nations (20). This situation creates a favourable ground for disease transmission and the proliferation of insects and other vectors thriving in the tropical climate of SSA.

Climate change is another great contributor to the spread of NTDs. It affects the behaviour, distribution, and life cycle of vectors (21). Furthermore, it causes an increase in desertification and drought which in turn reduces access to safe water. All these factors have an effect to increase the population at risk of the disease. Climate change is a determinant which must be addressed in order to ensure efforts put in place to curb the evolution of NTDs have the expected outcomes.

In the African context, conflicts are common; going from the numerous coup d’Etat the continent has witnessed to civil war initiated by the different rebel forces in some countries. In these conflict zones, access to basic needs is difficult and it is usually accompanied by the destruction of infrastructures leading to promiscuity (22). In such contexts, NTDs proliferate easily.

Conclusion

The fight against NTDs is intricately linked to the broader goal of poverty alleviation in Africa. Much has already been done to fight against NTDs as shown by the reduction in the burden of the diseases over the years. Despite these efforts, Africa is still particularly afflicted. By addressing the setbacks, which in turn will contribute to reducing the prevalence of these diseases and their impact on impoverished communities, significant strides can be made toward reducing unjust inequalities and improving the overall health and well-being of the population in the SSA region.

PROPOSED POSSIBLE SOLUTIONS

  • Increase funding allocated to NTDs research and development targeted towards preventive and curative methods.
  • Lectures on NTDs must be emphasized in all health-related training programmes in SSA.
  • Promote initiatives aiming to fight against climate change.
  • More awareness campaigns coupled with mass drug administration should be organized, and supported by community health workers as key actors.
  • Promote the use of advanced and big data analytical technologies which will favor strong and resilient surveillance systems.
  • Provide remote areas with potable and clean water.
Evrard Kepgang
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Kepgang Evrard is a young research and humanitarian passionate. He holds a master’s degree in Public health and epidemiology at the University of Dschang.

Dr Valery Ngo
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Dr. Ngo Valery Ngo is a Medical Doctor and a Senior Health Researcher at Nkafu Policy Institute, a think tank at the Denis & Lenora Foretia Foundation in Yaoundé, Cameroon. Before his appointment, he was a volunteer research assistant under Professor Bright Nwaru at the Krefting Research Centre in Gothenburg, Sweden, during which he conducted various researches in global health and contributed to various systematic reviews to synthesize existing evidence on major global health issues.

Dr. Bruna Djeunang Dongho
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Ghyslaine Bruna Djeunang Dongho, Ph. D., is the Senior Researcher in Global Health and Public Health at the Nkafu Policy Institute.

Regina Sinsai
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Regina Sinsai holds a Bachelor of Arts Degree in Psychology from the United States International University – Africa, in Nairobi and an HND in General Nursing from the Humanity Health Professional Training Center (HHPTC) in Yaoundé.

Solange Dabou
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Solange DABOU holds a Master of science in Clinical Biochemistry from the University of Dschang and have followed a distance learning training in epidemiology and health statistics from Aix Marseille University.

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Dr Ronald Gobina is a Nephrologist, working with the Regional Hospital in Buea. He is a Health Fellow and the Director of the COVID-19 taskforce for the DLF foundation. He is member of the International Society of Nephrology (ISN) and the Initiative to Strengthen Health Research Capacity in Africa (ISHReCA).

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