TropIKA Blog Portal

India's leprosy burden featured in documentary

The UK's Channel 4 TV has shown a documentary in which it is claimed that leprosy may be more common in India than official figures indicate. The programme features the remarkable work of people involved in the battle against the disease. More details and (for the next three weeks) a chance to view the programme online are available here.

Drugs for neglected infections could be "India's gift to the world"

Peter Hotez, that indefatigable campaigner for raising the level of action against the infectious diseases of poverty, has written an article for India's The Hindu newspaper. He seeks to emphasize both the magnitude of India's own disease burden and the strong position that the country is in to produce new drugs for these infections that will benefit Indians themselves and many others in disease-endemic areas. Hotez informs his readers that, "India and its South Asian neighbours account for one-quarter of the world's intestinal worm infections such as hookworm and roundworm, and more than one-half of the world's cases of elephantiasis, leprosy, and visceral leishmaniasis". India also continues to face a major malaria problem. As is the case elsewhere, there is a lack of incentive for industry in India to produce new treatments for these neglected diseases, as they mainly affect the poor who have little purchasing power. Hotez says the solution is for India to create "new strategies to link its government institutions and its powerful private biopharmaceutical companies together in a public-private partnership to stimulate innovation for the poor". He concludes his article:

"An Indian public-private partnership for NTDs could produce a new generation of drugs, diagnostics, and vaccines that will benefit all of South Asia, and indeed the entire world's 'bottom billion' – the 1.4 billion people in the world who live in extreme poverty. Innovation for the poor could truly become India's greatest gift to the world".

A long list

The list of the infectious diseases of poverty (IDPs) is a long one. How should the individual diseases on this list be prioritized when funding is allocated for their research and control? The third G-FINDER survey reports on the sources of research funding and on how it is currently being spent. In 2009 there was an increase in the proportion of funding coming from public institutions and a corresponding decline in what was received from philanthropic organizations. Is a trend perhaps emerging? In a TropIKA.net editorial [1], we ask what happens now. According to G-FINDER there are encouraging signs that funding is being distributed more widely amongst the individual IDPs. And at TropIKA.net we continue with our efforts to report on important new developments across the full range of these diseases. Our recent articles on tuberculosis, for example, include a news story highlighting the paucity of diagnostic tools for TB in children [2]; there are also reports on research to develop new diagnostic tests [3] and treatments [4] and a guest blog from the TuBerculosis Vaccine Initiative [5]. Malaria once again has once again featured strongly on TropIKA.net, with reports of several new research initiatives, one of which focuses on vivax malaria [6] which generally receives less attention than the falciparum form of the disease. Combining the use of bednets with preventive treatment [7] and the search for a single-dose cure [8] have been the subjects of other recent studies. Controversy has surrounded new research on the potential use of species of fungi that could reduce the ability of mosquitoes to transmit malaria [9]. One research group believes that the use of genetically modified (GM) forms of the fungi offers the most promising way forward. We are increasingly hearing of the use of genetic modification in the search for new tools for the control of the IDPs – whether this involves vaccines, drugs or vector control. But hostility towards the use of any form of GM technology is now widespread in many parts of the world. The release of GM mosquitoes in Malaysia, for the control of dengue fever, went ahead in the face of protests by environmentalists [10]. Scientists should lose no time in making major efforts to address public concerns about GM. New products developed with this technology must be acceptable to communities before they can be brought into use. Dengue has also been the subject of several other new reports on TropIKA.net [11,12,13,14,]. Indeed such is the increasing level of interest in this infection, of which there are 50–100 million cases every year, that the time must surely be coming when it can no longer be described as a “neglected tropical disease”. Cholera, in contrast, does not figure prominently on the research agenda, even though the current pandemic of the disease, which began in 1961, is showing no sign of weakening and may indeed be picking up speed – as we have discussed in a TropIKA.net editorial [15]. Other diseases also featured on TropIKA.net, and which still deserve the “neglected” label, include trachoma [16] leprosy [17] cysticercosis [18] and Buruli ulcer [19]. There is also a geographical aspect to neglect. It is easy to forget, for example, that malaria is a problem – not just in Africa and Asia – but also in many Pacific countries [20] and that many IDPs are still a burden in the Americas [11,21]. Whatever the disease, access to reliable information and to the findings of research is crucial for policy makers and practitioners. TropIKA.net aims to facilitate the process of communicating such information but access to scientific journals remains a problem in many of the world’s poorest countries [22].

Remembering leprosy

World Leprosy Day, held each year at the end of January, helps direct attention to an infectious condition that is too often regarded as being a disease of the past, when sadly it is still with us. Around a quarter of a million new cases are recorded each year. A few days after this year's event, it is instructive to look at national media coverage from around the world. Good news first from Jamaica, where there are plans to repeal the country's Leprosy Act. According to the Jamaica Observer, health minister Rudyard Spencer has told Parliament that, "the prevalence of this disease is very low in Jamaica at less than one case per ten thousand for the population; it is therefore regarded as having achieved elimination status and is no longer a public health concern". He explained the importance of providing multi-drug therapy (MDT) to Jamaica's remaining leprosy patients, but that there was no need to isolate them. The "archaic and inhumane provisions under the Leprosy Act" were, therefore, no longer necessary. There is cross-party support for repealing the Act. Tanzania is another country which, in 2006, reduced the prevalence of leprosy to less than one per 10,000 population. But there have been warnings that the battle against leprosy is not yet won, and of the dangers of complacency. Dr Mohammed Ali regional medical officer of Lindi, one of Tanzania's 26 administrative regions, is reported in the Citizen newspaper as saying: “Tanzania has managed to reduce the number of leprosy cases from about 35,000 to 2,600 but the disease is still a big problem in some parts of the country. Lindi is the mostly affected region. The other regions where the problem is also huge are Rukwa, Dar es Salaam and Mtwara”. The Nigerian government's position on leprosy was made very clear by health minister Professor Christian Onyebuchi Chukwu. Prevalence here fell below one in 10,000 in 1988, since when the number of registered cases has declined from 200,000 in 1989 to 4,899 at the end of 2008. But the minister said challenges still remained; he was concerned by the proportion of new cases (10%) who were children and by the continuing problem of late presentation of new cases to health facilities. He said steps had been taken to reduce stigma and discrimination against people affected by leprosy and their families, and that the government would continue to support initiatives to promote community-based rehabilitation (CBR). Further information is available in the Nigeria Compass. India's progress against the disease is slow, with some states lagging behind the national average. The Times of India reported the director of medical services in Tamil Nadu as being unhappy with the results of a recent survey showing the rate of infection in children was substantially above the national figure. With about 5,000 leprosy cases per year, Bangladesh ranks fourth in the world as a leprosy burdened country after India, Brazil and Indonesia. But it too is in the process of repealing its unhelpful "Lepers Act". bdnews24.com reports the comment of one politician that "Though the Act is not in practice in Bangladesh, it should be revoked as such law can taint the image of a country". Martin Adhikary, advocacy director of Leprosy Mission International, said repealing the Act was imperative to uphold human rights. Other concerns in Bangladesh are the issue of late presentation, the need to step up rehabilitation and integrate the provision of care. Sadly, however, the government ceased to observe World Leprosy Day some years ago, apparently because of the burden of observing so many other world days. In contrast, the Philippines has a Leprosy Week, taking place 13-19th February. Any initiative is of course to be welcomed if it highlights the continuing threat from leprosy, the need for early diagnosis, treatment and - crucially - for rehabilitation. Providing accurate information about leprosy through special days, weeks or other events can also help bring to an end the stigma still associated with this disease.

Individuals count

Efforts to combat the infectious diseases of poverty continue to expand and TropIKA.net reports frequently on the launch of new initiatives, the activities of institutions, the importance of empowering communities, and the need to create networks. It is all too easy to forget that progress, nevertheless, requires contributions from individuals. Few have contributed as much as Mariano Levin, best known for his work on Chagas disease, who died earlier this year. A TropIKA.net Profile [1] reviews his life and his legacy. We have also over the last few weeks reported on a number of new initiatives. These include the wonderfully named “This Wormy World” – an open-access information resource on the distribution of soil-transmitted helminths and schistosomiasis [2]. Also launched is a new organization that seeks to accelerate the development of new pharmaceutical products for the diseases of the developing world – formerly part of the George Institute and known for its influential G-FINDER survey, Policy Cures [3] has progressed to become an independent entity. The UK Department for International Development (DFID) has long been a major player in malaria research and control programmes. It now intends to develop a new “malaria business plan” [4] and has begun a public consultation as part of this process. In the USA, the announcement of the start of a dengue vaccine trial [5] comes at the same time as news of plans to start trials with a vaccine for leprosy [6]. Vaccines, drugs and other new tools are of course much needed, but so often things go wrong when it comes to delivering them to where they are most required. Praziquantel is a cheap and effective treatment for schistosomiasis, but less than 10% of school-aged children at risk are reached by disease control programmes [7]. But disease control programmes can be made to work. The global eradication of dracunculiasis (guinea worm) is drawing closer with further progress reported from West Africa [8]. Only in the southern Sudan is the relative lack of progress a cause for concern. Research TropIKA.net continues to highlight new research findings that are of particular interest. Recent examples include epidemiological research that has made possible the completion of a global map showing populations at risk of vivax malaria [9], molecular biological findings that bring new understanding of the metabolism of the malaria parasite [10], and studies in Australia that suggest that wild mammals may play a part in the transmission of Buruli ulcer [11]. But such research often seems a long way from the delivery of effective care. How interventions are brought to the individuals who need them also requires study. Much neglected, for example, is the role played by the retail outlets (often unlicensed) through which the majority of Africans obtain their medicines. A new systematic review [12] finds that little study has been made of efforts to improve the service such shops can offer. Nevertheless, there is some encouraging evidence that training programmes do help. Paul Chinnock Editor, TropIKA.net

Leprosy vaccine will begin safety trials next year

Scientists from the non-profit group the Infectious Disease Research Institute (IDRI) say they hope to have a leprosy vaccine ready for safety trials by 2011. A report in The Seattle Times says the vaccine has been in progress since the early 2000s, when IDRI was given a grant from the American Leprosy Missions. While leprosy case numbers have fallen, the disease is far from being eliminated globally and an effective vaccine would be regarded as a major step forward. In addition to a vaccine, IDRI is in the process of creating a blood test that would be able determine whether or not a patient is infected within 10 minutes. The Seattle Times report includes an interview with Scottish researcher Malcolm Duthie who heads the IDRI leprosy vaccine-development programme. He says, "Our belief is that a vaccine will give an active protection. If we can vaccinate people, we could potentially break the transmission cycle". The newspaper has also recently published an article on the activities of the Harborview Medical Center, one of 15 federal clinics in the US focused on patients with leprosy.

NTD news from Colombia

Nora Cardona-Castro of the Instituto Colombiano de Medicina Tropical - Universidad CES has written to us about the work of the Institute.

The Colombian Institute of Tropical Medicine "Antonio Roldan Betancourt" ICMT-CES is a center of excellence in research, nonprofit, described by COLCIENCIAS full exaltation granted by that organization: Group A1 "Institution of Excellence in research." It was founded in 1989 as a Joint Participation Corporation for purposes of public and social interest. Currently the Institute has an operating headquarters in the CES University facilities in the town of Sabaneta and another office located in Apartado - Antioquia. The ICMT is managed by the University of Medellín CES, an institution renowned for the quality of its academic programs and unconditional support to the development of research and science, as well as the provision of services, consulting and advisory services in the Colombian health sector and Latin America. ICMT-CES Mission Working continuously for the development of science, through research and academic training of health professionals, with the aim to contribute actively in improving the health of the citizens. Our Institute has international recognition, thanks to the work associated with other research institutions and the many publications of scientific contribution. ICMT-CES focuses its research activities in all areas of Tropical Medicine, based on epidemiology and immunology of infectious diseases, supported by the most advanced techniques of molecular biology for diagnosis. They stand out for their development research in progress: leishmaniasis, Chagas disease, intestinal parasites, salmonellosis, leprosy, tuberculosis, malaria, cysticercosis, dengue, leptospirosis, diagnostic methods, medical entomology and brucellosis.

The poor: where are they?

It is the world's poorest people who face the biggest infectious disease burden and who should, therefore, attract most attention in disease control efforts. But who are the world's poorest people and where do they live? The focus is generally upon Africa. For example, in the best-selling book The Bottom Billion, it was argued that the countries in which the poorest one billion people live are almost all in Africa. New research suggests, however, that a large proportion of the world's ultra-poor are in India. The Guardian (UK) reports that specialists at Oxford University have devised a new "multidimensional poverty index", according to which there are more poor people in eight of India's states than in the 26 countries of sub-Saharan Africa combined. The index uses 10 major variables including education, nutrition and sanitation. According to the index, more than 410 million people live in poverty in the eight Indian states, and the intensity of the poverty is equal or worse than what is found in Africa. For example, the Democratic Republic of the Congo (population 62 million) is perhaps the poorest nation in Africa, but India's vast central Indian Madhya Pradesh state (70 million) has a near-identical level of poverty. Many laudable efforts have been made in recent years to address poverty and disease in Africa. India's poor, in comparison, have been neglected. This is all the more tragic, given the impressive growth of India's national economy. From the research perspective, India's needs must help shape the agenda. Vivax malaria, dengue, visceral leishmaniasis and leprosy are amongst the infections which threaten the poor in many parts of India.

A "manifesto" for combatting NTDs

Despite evidence that the global burden of neglected diseases is as great as that of any other serious disease, financial support for elimination efforts and R&D has been inadequate, say the authors of a new "Manifesto for Advancing the Control and Elimination of Neglected Tropical Diseases", published this week. Writing in PLoS Neglected Tropical Diseases, Peter Hotez, President of the Sabin Vaccine Institute and Distinguished Research Professor of The George Washington University Medical Center, and Bernard Pecoul, Executive Director of Drugs for Neglected Diseases initiative (DNDi), outline in eight points why the global community should increase financial support for NTD control and elimination efforts and research and development. The manifesto states that:

· All NTDs are "tool ready" with cost-efficient and effective interventions that could be implemented now, even if for some diseases such tools are far from being perfect or complete.

· At the same time that NTDs are tool ready they are also tool deficient, signifying that the tools are incomplete, or inadequate, to sustain elimination efforts.

· NTDs have received little attention from the international community during the past ten years despite their large disease burden.

· Increasing evidence indicates an association between NTD prevalence and conflict and violation of human rights.

· NTDs can be particularly destabilizing and disrupt agricultural productivity and food security. Many poor societies with high NTD burdens have been recently engaged in a civil or international conflict or are currently at war.

· Sustained involvement by the WHO and other international health agencies is crucial for current and future NTD control and elimination efforts.

· Nothing is more important to the success of global NTD control than the involvement of communities themselves and disease-endemic countries' health ministries.

· Achievement of Millennium Development Goal 8 ("develop a global partnership for development") will rest with stakeholders — health ministries, affected communities, public–private partnerships, large and small non-governmental organizations, etc. — establishing a well-functioning international strategy for NTD control.

While acknowledging that policymakers are “slowly beginning to appreciate the importance of NTDs” — evidenced by the creation of a new department of Neglected Tropical Diseases at the World Health Organization; TDR’s 10-year strategic plan; and the identification, by NIH’s Francis Collins, of neglected diseases as a research priority, among other developments — Hotez and Pecoul argue that the challenge of NTDs calls for a manifesto — “a public declaration of motives by a government or by a person or group regarded as having some public importance.”

Moreover, they add, by doing more to tackle NTDs, the global health community can make progress toward Millennium Development Goals.

"[NTD control] activities have facilitated the delivery of additional interventions such as insecticide-treated bed nets, antimalarial drugs, micronutrients, and childhood immunizations," they write.

The authors urge scientists working on NTDs to increase collaboration and identify funding opportunities and cost-efficient interventions.

"By highlighting important challenges in the fight against NTDs, this 'manifesto' calls on the global community for urgent, renewed, and innovative efforts."

Neglected tropical diseases: debating the best way forward

An article [1] in PLoS Medicine's Debate series examines the different approaches that can be taken to tackle neglected tropical diseases (NTDs). Some commentators, such as Jerry Spiegel and colleagues from the University of British Columbia, feel there has been too much focus on the biomedical mechanisms and drug development for NTDs, at the expense of attention to the social determinants of disease. Burton Singer argues that this represents another example of the inappropriate “overmedicalization” of contemporary tropical disease control. Peter Hotez and colleagues, in contrast, argue that the best return on investment will continue to be mass drug administration for NTDs. Reference 1. Spiegel JM, Dharamsi S, Wasan KM, Yassi A, Singer B, et al. (2010) Which New Approaches to Tackling Neglected Tropical Diseases Show Promise? PLoS Med 7(5): e1000255. Available from: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000255

Leprosy: has "elimination" been misunderstod?

The elimination of a disease as a public health problem is a very different matter from eradication. The latter means wiping it off the face of the earth - a feat that has so far only been achieved with smallpox. Nevertheless, even at high levels of policy making, there can be some confusion between the two terms. A Lancet article, written to mark World Leprosy Day, raises the question as to whether a misunderstanding of the concept of elimination has hampered leprosy control efforts. The World Health Organization defines leprosy elimination as reducing the level of prevalence to below one in 10,000 of the population. Most of the countries that were formerly highly endemic for leprosy have now achieved elimination by this definition, but many of those same countries (most notably India) still have many cases of leprosy. According to the article, many countries stepped down their efforts against leprosy once the elimination target had been reached. In consequence progress against the disease, of which there are still around a quarter of a million new cases every year, has thus suffered. The article also refers to a new report from WHO's Southeast Asian Regional Office (SEARO) which puts forward a new strategy for further reducing the disease burden due to leprosy. Most notably, under this strategy, the rate of new cases with grade-2 disabilities among new cases per 100,000 population would be used as a key indicator to monitor progress. TropIKA.net's own coverage of World Leprosy Day 2010, which emphasized the role of research, may be accessed here.

They think it’s all over ...but it isn’t

One of the barriers to increasing the level of support for research and control of the infectious diseases of poverty (IDPs) is a widespread view that many of these infections are already in decline, and that little more needs to be done before they are eliminated. Leprosy is a case in point; this year’s World Leprosy Day has already been and gone, but attracted little media attention. Here on TropIKA.net, however, we have argued [1] that the battle against leprosy is far from over and that there is a need for further research; we seek to identify the research gaps that need filling. Thankfully, some other IDPs are now receiving increased attention and there is good news to report. New findings from southern Africa and from Mexico [2] provide further evidence that the introduction of rotavirus vaccines into immunization programmes can lead to substantial reductions in diarrhoeal morbidity and mortality. (Diarrhoeal disease is, after pneumonia, the second biggest killer of children in poor countries.) Getting the vaccine to all those who need it is now the challenge. The search for a vaccine that will protect against dengue fever [3] has been stepped up, with another candidate vaccine entering Phase 1 trials. There are now at least five potential dengue vaccines under development. Some of the countries in Asia and South America reporting increased numbers of dengue cases are amongst the world’s most rapidly growing economies. There will certainly be a significant market for products that prevent or treat dengue and thus there is an economic incentive for research and development efforts that is lacking for many other IDPs. Many infectious diseases have now been studied using the techniques of mathematical modelling but it remains a controversial area of research. In one of our regular series of Profile interviews, Tatum Anderson speaks with one of the leaders in this field – Professor Sir Roy Anderson [4]. But probably the most influential figure in IDP research is now Bill Gates, who has been much in the news in recent days. The publication of his Annual Letter is likely to come to be regarded as a yearly landmark, as it sets out – in an informal fashion – the Gates Foundation’s own current plans and priorities, and it will have an influence on the actions taken by other donor organizations. The letter – and the announcement of major new Gates funding for vaccine research that followed a few days later – are discussed in TropIKA.net News [5]. The TropIKA.net Blog [6] continues to highlight new developments that have been reported elsewhere on the Internet. China has been reported to have made good progress against tuberculosis [7] and market research has shown it to offer enormous potential for the sale of TB drugs [8]. The achievements of China contrast with the situation in South Africa where TB rates in children are claimed to be the highest ever reported [9]. Another item of interest on the blog is the news that drug giant Novartis has been trying to create a fund that companies and institutions could draw upon to finance the development of drugs against neglected diseases. But after two years of approaching potential donors Novartis says it has not raised a cent for its proposal [10]. Industry has a major role to play in the development of new tools to control the infectious diseases of poverty and it is to be hoped that Novartis will find other ways in which it can make a contribution. Paul Chinnock Editor, TropIKA.net

Sainthood attracts attention to leprosy

Leprosy is in the news at the moment, the Roman Catholic Church having this week canonised Jozef De Veuster ("Father Damien of Molokai"). Already widely regarded as the spiritual patron of efforts to fight leprosy, he is now formally a Saint - see Associated Press report. Saint Damien won recognition for his ministry to people with leprosy (also known as Hansen's disease), who had been placed under a government-sanctioned medical quarantine on the island of Molokai in the Kingdom of Hawaii. He eventually contracted and died of the disease in 1889. Since Saint Damien's time, much progress has been made against leprosy but many barriers still need to be overcome before the disease is eradicated. Over 200,000 people worldwide are registered with leprosy and some two to three million people are estimated to be permanently disabled as the result of the disease. India has the greatest number of cases, with Brazil second and Burma third. Stigma, even against people who no longer have leprosy, holds back control efforts. Highlighting the work of Saint Damien may help renew global efforts to fight the disease. Commenting on the canonisation, President Barrack Obama said Father Damien’s life should stand as an example for how to deal with modern-day diseases - see ABC News report. Obama's comments are of interest given that the President, who of course was born in Hawaii, has chosen to increase the funding that the US provides for the control of neglected tropical diseases - see TropIKA.net News.

Funding drive to support the fight against neglected infections in the Americas

The Inter-American Development Bank and the Global Network for Neglected Tropical Diseases have announced their intention to mobilize $30 million from the public and private sectors to raise awareness and funding for the control and elimination of neglected tropical diseases (NTDs) in the Americas region. Technical assistance for the initiative will be provided by the Pan American Health Organization (the regional office of the World Health Organization). The announcement was made at the annual meeting of the Clinton Global Initiative in New York - see press release. The meeting heard that soil transmitted helminths and Chagas disease cause the greatest NTD burden in the Americas, followed by dengue, schistosomiasis, leishmaniasis, trachoma, leprosy, and lymphatic filariasis. More than 230 million people in the region are currently living with these devastating diseases. Partners involved in the new initiative range from the Brazilian soccer team to pharmaceutical giant GlaxoSmithKline (GSK) and Partners for Philanthropic Change. GSK has also recently announced that it will provide Brazil with some of its vaccine technology and also fund research in Brazil for a vaccine for dengue fever - see Wall Street Journal.

India's antiquated laws on leprosy

Out-of-date laws seriously infringe the human rights of people with leprosy in India. According to the laws of some Indian states they cannot hold a driving licence, travel by train or stand in local elections. Having leprosy is also grounds for divorce. The employment that people affected by leprosy are allowed to perform is restricted, and the restrictions remain even years after a person has been cured. An article in the Hindu newspaper calls for the antiquated laws to be changed.

Do TB bacteria form spores?

A press release from the University of Uppsala in Sweden reports a study that opens the possibility that the organism responsible for tuberculosis (Mycobacterium tuberculosis) might be able to form spores. This goes against all current understanding of the Mycobacteria. It is known that M. tb. can remain latent in infected people for many years. Indeed this is one of the reasons why TB is so hard to control. But it is unclear how the organism manages to achieve its latency. Many other bacteria use spores but not, so it seemed, M. tb. Leif Kirsebom and colleagues say they have now shown that, not M. tb. but a 'close relative', can form spores. Apparently their discovery was initially an accidental finding. The research has not yet been published but is expected to appear shortly in the Proceedings of the National Academy of Sciences. It is to be hoped that this new knowledge of the Mycobacteria might ultimately lead to new ways to control TB and other mycobacterial diseases in humans and animals. These include leprosy and Buruli ulcer.

Leprosy apology

TropIKA.net has offered featured instances of stigma and discrimination of people with leprosy. In a remarkable development in South Korea, the Prime Minister has made an official apology to a group of people with the condition for the treatment they have received over the years. The Korea Times reports the words of Prime Minister Han Seung-soo at a ceremony to mark the Day for Leprosy Patients at Sorok Hospital. Leprosy patients on Sorok Island, says the Times, "have maintained an isolated and repressive life for decades." The PM said, "It took so long for the nation's prime minister to meet people with leprosy. On behalf of the government, I offer deep apologies and condolences to the patients and their families who had unspeakable suffering amid social discrimination and prejudice.'' He went on to promise that the government would now take "substantial action" to protect the rights and welfare of people with leprosy.

Stigma against leprosy prevents patients coming forward for treatment

TropIKA.net has covered a number of stories indicating that prejudice against people with leprosy is disturbingly common in India. There have been calls for people with leprosy, to be prosecuted should they have children (see blog) and not long ago India's Supreme Court upheld a ruling that leprosy patients cannot contest a civic election or hold municipal office in Orissa State (see BBC News). It is good therefore to see a report of a programme in Allahabad which is making progress in efforts to provide treatment and support for people with the disease. Part of the programme is the provision of reconstructive surgery but very few leprosy patients have taken advantage of this. It is thought that their unwillingness to come forward is a consequence of the widespread stigma against leprosy. The programme is making efforts to improve awareness of the disease. Early diagnosis is seen as another priority. See report in the Times of India.

Reports of relevance

Banks are interested in money and their take on health issues is different ...but important. A report from the Asian Development Bank, recently featured on the TropIKA.net blog, examines the economics of climate change, based on a major 15-month study. The ADB believes that there are several mechanisms through which changes in climate will impact on the economy, one of which is via the effects on human health. For health specialists, human health and wellbeing are ends worth pursuing in their own right and not just a requirement for economic growth. Nevertheless, this report is well worth a look. The ADB notes that increases in temperature could lead to more malnutrition and more diarrhoeal disease, but the threat it discusses in most detail is further increases in dengue fever rates. Now that dengue has been officially recognised as a danger to the economy, will it remain a neglected disease or will we see an increase in funding for research and control efforts? As we noted in a recent TropIKA.net News article new directions for dengue research are opening up, but adequate support will be required for them to be pursued. Another bank, the World Bank, has just published a frank and transparent evaluation of the effectiveness of the health programmes within its ‘portfolio of investments’. Nearly half of the Bank’s health support is for action against infectious diseases. However, almost 90% of the infectious disease programmes it supports are focused on just one disease – HIV/AIDS. Critics have said that this disproportionate emphasis has distorted health priorities in countries receiving Bank assistance. Also of great concern is the fact only a minority of Bank HIV/AIDS programmes (29%) have performed satisfactorily. In contrast most (89%) of the programmes devoted to other infections are regarded as being satisfactory. There must surely be two conclusions here. Firstly, better ways must be found of addressing HIV/AIDS. (No one would argue that the Bank or the international community at large should give up on this disease.) But secondly, since the evaluation has established that action against other infections (such as schistosomiasis, leprosy, malaria and TB) offers good value for money, investment in such programmes should be increased ...if only on economic grounds. Also recently featured in the TropIKA.net Reports section is a document from UNICEF: Malaria & Children: Progress in Intervention Coverage. Although UNICEF believes that “We are, for the first time in history, poised to make malaria a rare cause of death and disability” many outstanding challenges are noted in this report. Progress in getting effective antimalarial treatment to all who need it has been slow and the number of pregnant women who sleep under insecticide-treated nets is still much too low. The latter point has been underlined by recent news from Liberia. As well as highlighting important news and reports published elsewhere, TropIKA.net continues to publish original content. Our recent extended interview with Michael Gottlieb, head of the Grand Challenges project at the Foundation for the US National Institutes of Health is of particular interest, as it comes at a time when the entire Grand Challenges in Global Health project – a research funding initiative that is worth almost half a billion dollars – is at a crossroads. Paul Chinnock Editor-in-Chief, TropIKA.net

World Bank malaria and TB projects do better than those on AIDS

Seven of 10 AIDS projects financed by the World Bank have been found to have "unsatisfactory outcomes" according to an internal Bank evaluation. In marked contrast, nine of 10 of other infectious disease projects performed satisfactorily or better. The Bank's report is discussed in a New York Times article. The article notes that: "While the focus on AIDS accounted for nearly 60 percent of the bank’s projects on communicable diseases from 1997 to 2006, more successful efforts aimed at malaria, tuberculosis and leprosy, among others, got far fewer resources. Malaria, for example, made up 3 percent of the projects, and tuberculosis only 2 percent." It also quotes William Easterly, an economics professor at New York University, as saying that the evaluation confirmed for him “a fear that many of us have had for some time: that hugely disproportionate attention to AIDS has had a negative effect on aid efforts for all other health problems.” The evaluation concludes that AIDS projects were often over-ambitious and that many were too complex for the weak or inexperienced bureaucracies carrying them out. The evaluation is available on the World Bank website.

Progress in Mozambique is marred by cholera

The current cholera epidemic in Africa is producing some worrying statistics ...and news headlines. Mozambique for example has released new figures showing that, since the start of this year, over 13,000 Mozambicans have been diagnosed with the disease, compared with about 12,000 for all of 2008. There have been 140 deaths so far this year; there were 150 in the whole of 2008. Mozambique has a long border with Zimbabwe, which currently has the most severe cholera problem and has become a major exporter of the disease. However, Mozambique has progress to report as regards other infectious diseases of poverty. Leprosy is no longer regarded as a public health problem in the country. In 2008, all provinces in Mozambique recorded less than one case of leprosy per 10,000 inhabitants. Measles vaccination campaigns have led to a dramatic reduction in notified cases, by over 95 per cent in three years. In 2005, the health authorities recorded 12,598 measles cases but in 2008 the figure fell to 278. From 2007 to 2008 the number of known cases of malaria also fell by 24%. The health ministry attributes this to recent campaigns of of insecticide spraying against mosquitoes, and improvements in malaria diagnosis and treatment. (Malaria of course often does vary greatly from one year to the next.) The figures were released by Health Minister Ivo Garrido during a meeting of his ministry's Coordinating Council. They are reported on allAfrica.com.

Will the poor suffer most?

What impact will the global economic decline have on the lives of the poor? Will it reduce the already inadequate funding for research and control programmes devoted to the infectious diseases of poverty? Kofi Annan fears that it may indeed be the poor who suffer most and he calls for a “coordinated global stimulus” which will benefit the least developed countries. But there is simply less money around just now. No one can avoid the effects of the financial crisis – sadly not even the Gates Foundation, which plays such a crucial role in global efforts to eliminate infectious disease. Infectious diseases add of course to the economic burdens faced by developing nations. Nevertheless, it is hard to quantify their impact. TropIKA.net has recently published a summary of preliminary calculations made by the Indian Institute of Management, Ahmedabad seeking to calculate the economic cost of dengue fever. This comes at a time when there are indications that, in Asia, dengue may be more common than shown in official figures. The prevalence and incidence of many other diseases may also be under-estimated. A recent survey suggests that India’s progress towards the elimination of leprosy may be less impressive than has been claimed. It is good to know therefore that a useful dialogue on issues related to leprosy still continues. Playing a part in this is the Leprosy Mailing List, one of the mailing lists featured in our Networking section. It is not disputed that rates of tuberculosis are high in China but the consequences may be even more serious than recognised. A new study provides evidence that the infection increases the risk of lung cancer. My selection of new content on TropIKA.net does seem to have focused on the bad news this time around, so let me finish with a positive research finding – chloroquine, once the mainstay of malaria treatment, has been found to be active against two emerging threats to health, the Nipah and Hendra viruses. This is a drug which should not be consigned to history. At a time like this we need some old friends around us! Paul Chinnock Editor-in-Chief, TropIKA.net

Sierra Leone must not forget leprosy

allAfrica.com has an encouraging report on leprosy control efforts in Sierra Leone, where the number of new cases fell from 598 in 2007 to 448 in 2008. The country now has less than one case per 10,000 people, meaning that the disease is not considered to be a public health risk. "Leprosy seems to be going down every year," says Dr Foday Dafae, who manages the Ministry of Health's National Leprosy and Tuberculosis Control Programme. However, Antoinette Fergusson of the German Leprosy and Tuberculosis Relief Association, which supports the national programme, said it was important not to forget about the disease. It is still widely regarded in Sierra Leone as being caused by witchcraft and people with leprosy suffer from stigma. Read the full story here.

Uganda's progress against leprosy

Uganda's health minister, Dr Stephen Mallinga, says over 16,000 people in the country have now been treated for leprosy and declared cured. There were 389 reported cases of leprosy in 51 Ugandan districts in 2007. The National Tuberculosis and Leprosy Programme estimates that about 3,000 people have disabilities and socio-economic problems as a result of leprosy. The manager of the programme, Dr Francis Adatu-Engwau warned against the stigmatization of leprosy patients, saying “It is worth noting and indeed rewarding to all those who take care of leprosy patients that the majority of these lives are free from consequences of the disease. This is attributable to the highly effective treatment given to the leprosy patients.” The full story is on New Vision Online.

"Cured of leprosy, they help build car engines"

After a number of disturbing reports of prejudice against leprosy patients in India (see for example in the TropIKA.net blog), it is truly heartening to read, in The Times of India, about a successful project which has given employment to leprosy-cured patients (LCPs). "Despite being cured, we were not accepted", one of the LCPs told The Times, but a cooperative, which was set-up in 1983, now employs over 100 LCPs who make engine components. Motor giant Tata is amongst their customers. The cooperative was set up under the guidance of Dr Jal Mehta, who helped rehabilitate the LCPs after using innovative surgical techniques for correcting their deformities at the Bandorawala Leprosy Hospital in Kondhwa. LCPs say that Dr Mehta has enabled them to hold their heads high.

India's strangest stigma story

Stigma against people with infectious diseases is counterproductive and in most cases irrational, based on misunderstandings of the nature of the disease. People with leprosy have been particularly likely to suffer from stigma and in India this problem still remains. Now, however, The Hindu newspaper reports that a call has been made by the chairman of the Andhra Pradesh Human Rights Commission, B. Subashan Reddy, for people with infections including tuberculosis and HIV, as well as leprosy, to be prosecuted should they have children. (Parents with dyslexia would also be prosecuted.) The Hindu has published the excellent response from three doctors who say that “the statement is devoid of any substance or rationale” and that “making irresponsible and ill-considered statements like this could lead to further stigmatisation and ostracisation of an already marginalised population.” The doctors point out that TB and leprosy are not heritable conditions and ask whether people with latent TB would be liable for prosecution. (Half the population of India is infected with TB.) Concerning HIV, the doctors say that: "Mother-to-child transmission accounts for less than 4 per cent of new infections in India — even these can be prevented by screening and timely treatment of pregnant women. HIV is now a treatable chronic illness and no longer the death sentence it used to be." Enforcing the kind of legislation that Mr Reddy has called for would be impossible. The real tragedy is that such attitudes - and such ignorance - can still be found amongst people in positions of authority in the 21st Century.

Leprosy organization holds meeting

The Times of India reports a meeting of the International Leprosy Union, which is based in the Indian city of Pune, near Mumbai. Speakers included Indranath Banerjee, national professional officer of WHO. He reported that, there were around 5,09,000 cases in India in 1999, but by 2008 there were only 82,000. He said that 29 of India's 35 states and union territories had achieved the target for leprosy 'elimination' of fewer than one case per ten thousand population. Sharadchandra Gokhale, president of the International Leprosy Union said it was working towards the upgrade of facilities at the Kondhwa Leprosy Hospital. He said leprosy patients should do more to 'stand on their own' to improve their self-respect.

Leprosy in the USA: 'not common but not gone'

Reports on the occurrence in wealthy countries of 'tropical' diseases (infectious diseases of poverty) are of some value. These are not of course the countries where such diseases have most impact, but it is useful to be reminded that everyone is potentially vulnerable to infectious disease. Without this realisation, there is a danger that policy makers in the developed world will forever think of infections like dengue fever, Chagas disease and leishmaniasis as 'exotic' conditions only affecting strangers in far away lands. It has been reported that more cases of advanced leprosy (Hansen's disease) are being seen in the USA. American doctors, being unfamiliar with the condition, often fail to diagnose it early on. Dr James Krahenbuhl, Director of the US Department of Health and Human Service’s National Hansen’s Disease Pogram said, “We are seeing more and more cases that are advanced.” Speaking at the annual meeting of the American Society of Tropical Medicine and Hygiene, Dr Krahenbuhl said that about 150 new cases of leprosy were diagnosed in the US every year. In total, about 6,500 people currently have leprosy, with about half needing active medical management. He called for greater awareness of leprosy among American doctors. Another leprosy specialist Dr David Scollard, said, “Although this disease is not common, it’s also not gone."

Translational research for neglected diseases

Translational research can be defined as the process that leads from evidence based medicine to sustainable solutions for public health problems, with the ultimate goal of improving the health of the population. It is a novel approach to medicine and research that also takes basic and social sciences into consideration when seeking new solutions for old public health problems. As such, neglected infectious diseases are very good candidates to be approached under the view of translational research. In Brazil the first steps in this direction were taken last November in Rio de Janeiro, when a small working group that included researchers, politicians, private funding agencies and business representatives spent two days debating the requirements and applied strategies for a translational research for neglected diseases programme to be successfully established in Brazil. The first need noted by the working group is that the cycle between poverty and neglected diseases must be broken. Poverty leads to the emergence and establishment of neglected diseases but the contrary is also true, with the occurrence of neglected diseases leading villages and populations into poverty. According to the working group, this catch 22 can only be broken when neglected infectious diseases are considered as a priority by governments. This has been the goal of a new programme created in Brazil that gives special attention to seven diseases, namely Chagas' disease, dengue, leishmaniasis, leprosy, schistosomiasis, malaria and tuberculosis. The programme has received around US$10 million in the last two years (2006-2007) from the Brazilian Ministries of Health and of Science and Technology. For this and other programmes to be transformed into translational research programmes, the working group stressed the need for more and better compounds that can work as antigens to be used for the development of new medication and vaccines against these diseases. Equally important is the creation of mechanisms that facilitate the implementation of pre-clinical studies and clinical trials, and the involvement of the Brazilian agency responsible for the approval of new drugs, toxicology tests, and the importing of equipment and consumables for research. The group suggested as the next step that a list of projects be selected for receiving funding provided by partnerships between the government and private companies interested in fostering translational research for neglected diseases. More details, in Portuguese, can be found in the website of the Brazilian Ministry of Health.

Legacy of leprosy isolation

A fascinating article in the New York Times describes the lives of the 24 remaining people with leprosy still living in the former leprosy settlement of Kalaupapa in Hawaii. For over 100 years leprosy patients were forcibly isolated in Kalaupapa. One resident was the Catholic Priest Father Damien who did much to improve the lives of the residents when he arrived in 1873. He subsequently contracted the disease. Another famous resident was Olivia Breitha who once wrote, 'Even if my skin is insensitive my heart and soul are not'. Hawaii eventually did away with its isolation laws in 1969. Earlier this year, the state’s Legislature formally apologized to the patients and their families for 'any restrictions that caused them undue pain as the result of government policies surrounding leprosy.' However, isolation settlements don't just disappear when legislation is changed. The 24 remaining leprosy patients (they prefer 'patients' to 'residents') are all over 60 and seem unlikely to leave Kalaupapa. The NYT article includes some of their memories of their lives in the settlement. The article can be seen here.

Leprosy: Australian doctors learn from East Timor

In Australia's more remote regions a few cases of leprosy occur every year (typically one to four) but, because the disease is so rare, doctors find it hard to diagnose. A report from the Australian Broadcasting Corporation describes how a group of doctors visited East Timor, where the disease is sadly still common, to improve their diagnostic skills. The doctors are said to have found their visit 'extremely useful' and their Timorese colleagues were proud to be able to share their expertise. The report (text and a podcast) also includes information on the leprosy situation in East Timor, one of three countries worldwide where leprosy has not yet been reduced to a level where it is considered to have been eliminated as a public health problem. (The other countries are Brazil and Nepal.) It is hoped to achieve elimination levels within the next decade.

Tuberculosis and leprosy

TB and leprosy are caused by different species of mycobacteria. Are people with one of these two diseases at heightened risk of developing the other? It is perhaps surprising that little research seems to have been done on this question. A study (1) from India, where TB and leprosy are both public health problems, has now examined the issue. The researchers retrospectively reviewed the case histories of 4,143 leprosy patients admitted between April 1976 and August 1985. One hundred and one were found to have evidence of tuberculosis. Of these cases 82 were pulmonary (35 sputum positive). Comparing the prevalence of TB in these leprosy patients with results for other Indian populations, the figures are similar. The authors conclude that leprosy patients do not seem to suffer more or less from tuberculosis as compared to the general population. They point out the limitations of this kind of study, however, and call for a pre-planned properly conducted study among leprosy patients. Reference 1. Saxena P, Ramu, G (1987). Association of tuberculosis and leprosy. Indian Journal of Tuberculosis; 34(4)197-199. [Study may be accessed via OpenMED* here.] *OpenMED@NIC is an open access archive for Medical and Allied Sciences. Here authors / owners can self-archive their scientific and technical documents. For this they need to register once in order to obtain a user id in OpenMED@NIC system. However no registration is required for searching the archive or viewing the documents.

Innovations and lessons from history

Examples of the innovative use of new technology to help to control the infectious diseases of poverty are often featured on TropIKA.net. The mobile phone is a piece of new technology that has been adopted enthusiastically across the developing world and the ready availability of these now ubiquitous devices has been put to good use by a team of software developers. An application which can be downloaded to mobiles has been used within a successful campaign to bring under control Kenya’s first polio outbreak for 21 years. See Mobile phone technology helps contain disease outbreak. Of the diseases on the TropIKA.net priority list, it is tuberculosis that has been most in the headlines over the last few weeks. We have summed up some of the most important developments in our article, Tuberculosis profile rising. Malaria also receives more attention from the international media than was previously the case. The World Malaria Report for 2008 was reported by many newspapers worldwide and (as I write this latest Editor’s Choice column) news is coming in of agreement at the UN for major new funding for malaria control. However, the excitement over new developments and innovations should not mean that the lessons of history are forgotten – see Malaria control: ‘faulty intelligence’ led to mistakes. One such lesson is that gains made in infectious disease control so easily can be lost. Having brought rabies under control for several years, China now seems to be facing a resurgence of the disease – see Renewed rabies vigilance needed in China. The increasing number of dengue fever cases is a major problem affecting a much wider area. The situation in the Asia-Pacific region and also Latin America is of increasing concern. One recent research article that has been the subject of a commentary on TropIKA.net is a systematic review examining dengue outbreak prediction and detection tools – see What does dengue disease surveillance contribute to predicting and detecting outbreaks and describing trends? As well as commenting on recently published research article, TropIKA.net highlights review articles of particular importance. Sleeping sickness and Chagas’ disease are often featured on our knowledge platform and a recent review is relevant to both of them – see Trypanosomiasis vector control in Africa and Latin America. An infectious disease that also takes a major toll but which is often forgotten and has not previously appeared on TropIKA.net is bacterial sepsis – see Strategies to Reduce Mortality from Bacterial Sepsis in Adults in Developing Countries. >blog. Responses to what our bloggers are saying are always welcome. Paul Chinnock Editor-in-Chief, TropIKA.net

TropIKA.net news exclusives

Leprosy has not appeared frequently on TropIKA.net but we have recently published an in-depth interview with Yohei Sasakawa, chairman of the Nippon Foundation, who highlights the human rights aspects of the fight against the disease. Yohei Sasakawa’s account of his life-long personal involvement in this cause makes for compelling reading.

Our recent news stories also include coverage of the imminent announcement of a new funding mechanism – the Advance Market Commitment (AMC) – intended to stimulate the development and manufacture of new vaccines against the infectious diseases of poverty. But the AMC already has its critics, as discussed in our article.

Infectious diseases of the nervous system: Pathogenesis and worldwide impact

Infectious diseases of the nervous system: Pathogenesis and worldwide impact is an international conference that will take place in Paris,10-13^th September, 2008. The conference aims to gather a group of experts in a number of infectious diseases that attack our nervous system. The two keynote lectures on the opening day will be [The brain, Africa’s finest and most vulnerable product’ given by Professor Malcolm Molyneux of the Malawi-Liverpool-Wellcome Trust Clinical Research Programme in Blantyre, Malawi and ‘Community-based care for infectious diseases in rural areas of developing world’ given by Professor Paul Farmer, who is a Professor of Medical Anthropology at the Harvard Medical School and Director of Partners in Health Clinics in Haiti and Rwanda. The scientific programme includes the following lectures: ’Trypanosoma Brucei triggers its own multi-step entry into the brain’, by Krister Kristensson at the Karolinska Institute in Stockholm, Sweden; ’Importance of microvesiculation in the immunopathology of cerebral malaria’, by Professor Georges Grau of the Institute for Biomedical Research at University of Sydney, Australia; and ’Signaling mechanisms for survival of leprosy bacteria in the peripheral nervous system’, by Anura Rambukkana at Rockefeller University in New York, USA; among others. More information about the conference, including the complete scientific programme can be found on the conference website.

Alligators’ resistance to infection could lead to new drugs

The popular expression ‘crocodile tears’, meaning insincere weeping, is of course not based on biological science. The blood of another reptile has, however, recently come under the research spotlight and with interesting results. Researchers from Louisiana State University (LSU) say their work on the blood serum of alligators could lead to promising new drug development against some major human pathologic bacteria and virus species. The announcement (1) was made during the 235th American Chemical Society National Meeting (ACS), held in New Orleans, United States, 6-8th April, 2008. According to the study, alligators are born with an innate immune system; they can react against antigens with which they have not previously come into contact. Study co-author Lancia Darville, from LSU, believes that peptides (fragments of proteins) within alligator blood help the animals avoid otherwise potentially fatal infections. ‘We are in the process of separating and identifying the specific peptides in alligator blood. Once we sequence these peptides, we can obtain their chemical structure to potentially [create new] drugs’, said Darville, as reported by National Geographic. According to the researcher, such peptides are also found in the skins of frogs and toads, as well as in komodo dragons and crocodiles. The research team exposed 23 species of bacteria to the serum extracted from alligator blood and as a result all the bugs were killed. Humans typically can defeat only eight of the bacteria. Co-author Mark Merchant, a biochemist at McNeese State University in Lake Charles, Louisiana, was among the first to notice alligators’ unusual resistance to infection. Initial tests, however, have revealed that higher concentrations of the reptile’s serum are toxic to human cells. Therefore, it is still going to be a while before we can expect to find ‘croc tablets’ replacing antibiotics. Reference 1. Darville, L.N.F., K.K. Murray, and M.E. Merchant (2008). Proteonomic analysis of the American alligator (Alligator mississippiensis) serum using 2-D-gel separation and mass spectrometry (Presentation ANYL 81). American Chemical Society meeting. April 6-10. New Orleans.

TropIKA: an expanding resource

During the last month much has been added to the content of TropIKA.net. Most of it has been in the News section, where some 20 stories relevant to tropical disease have appeared. We hope soon to be publishing around 10 news stories every week. We have also had two excellent Editorial Opinion articles, which we hope will stimulate some productive controversy. The second of our series of interviews with leading figures in tropical disease research and control is about to go live in our Stakeholders section. There is also a short announcement about our plans to commission specially written articles for the Reviews section, which will play a central role in TropIKA.But TropIKA is not just a place where new articles are published. We seek to provide a portal that will allow anyone with an interest in tropical diseases to link to what is going on in this growing field. Thus, also within the last month, we have added links to recent Reports and Policy & Strategy documents published elsewhere. We are also starting to develop our Funding Opportunities section. Sometimes, one comes across an initiative that is particularly pleasing. A new addition to the websites listed in our Resources section is a case in point. The website http://www.tsetse.org/provides highly practical ‘information to assist in the planning and implementation of tsetse control operations’. It is very encouraging that neglected tropical diseases are not neglected on the World Wide Web but it is not always easy to track down what is out there. Helping link people to resources is a key part of what we do. Paul Chinnock - TropIKA, Editor in Chief

Technology + Scientific knowledge = “Tech-knowledge”?

Hot off the press, a report from the International Symposium on Equitable Access to Health Care and Infectious Disease Control that was held in Rio de Janeiro last year, has fallen into my lap. Coincidentally one author of the report, which was published by UNRISD, is Claudia Travassos, a researcher at The Oswaldo Cruz Foundation (FIOCRUZ) and member of the TropIKA.net Advisory Board. The focus of the report is closely related to discussions about start this week, during Beijing’s 2007 Forum 11- namely Equitable Access. One theme that really popped out is the never-ending debate over “targeting vs. universalism” public health policies approaches and its relevance to equity in health care access. Especially the “targeting” approach quest for defining the so called “deserving poor” category?. As the Nobel Prize-winning economist Amartya Sen once has argued, “Benefits meant exclusively for the poor often end up being poor benefits”. In fact, according to Thandika Mkandawire, another author of the Rio report, “the choice between targeting and universalism approaches is ultimately a political economy problem, because it involves choosing instruments for the redistribution of resources in society and for determining levels of social expenditure”. On the other hand, as long as the spectrum of diseases covered by TropIKA.net is concerned, Mauricio Barreto, who also took part in the report, summarizes: “it will be important to develop and use international law; to clarify the moral and ethical basis for the control of infectious diseases; to enhance epidemiologic surveillance at the international level; to strengthen the means of controlling infectious diseases; to improve national and international communications to better manage outbreaks; to support the primary care basis of health systems; and to expand and strengthen North-South and South-South cooperation, and finally, to improve the development and transfer of scientific knowledge and technology”. So, what do you think now about the title of this post? Ok, it might be a pretty good pun, but it does make a lot of sense, doesn't it?