Don't Shoot the Messenger

The incredible fervor surrounding the recent publication of articles calling into question the evidence of benefit for mass deworming treatment highlights the passion and commitment of the neglected tropical disease community. This is not simply an academic debate. This conversation highlights very real tensions within the global health community between the need for continued advocacy to ensure that individuals in some of the poorest and most marginalized communities continue to benefit from a proven interventional strategy and the need for policymakers and planners to be able to determine priorities for resource allocation. The very fact that this passionate debate is occurring is clear evidence of the need for more robust data to inform this conversation. In this editorial, I present my own personal reflections and thoughts regarding what I consider to be an important moment of opportunity for our community. Decision making in public health is complex. Funding for global health appears to be stabilizing, and both policymakers and funders are being faced with difficult decisions regarding the prioritization of resources [1]. Increasingly, efforts are being made to ensure that available health funding is being allocated based on sound evidence-based assessments of impact. An improved understanding of the global burden of disease through efforts by groups such as the Child Health Epidemiology Reference Group (CHERG) and the Institute for Health Metrics and Evaluation (IHME), combined with economic analyses from groups such as Disease Control Priorities, Edition 3 (DCP3), seek to prioritize which health interventions are likely to have greatest impact by attempting to make the best use of available evidence [2–4]. However, even as some argue, as noted by Hicks, Kremer, and Miguel in this edition of PLOS Neglected Tropical Diseases, that “. . .the available evidence does suggest that mass deworming treatment should remain a policy priority in endemic regions,” we must also acknowledge that the available evidence does not uniformly suggest benefit and, at best, appears to demonstrate fairly modest impact only among those with documented infection [5,6]. Advocates of mass drug administration point out that such a delivery strategy is not predicated on the overall population benefit but is based on the logistical and practical benefits of treating everyone instead of attempting to diagnose and treat those with documented infection. However, treating all children in an effort to reach those with worms does cost governments and donors. Even with the massive donations of drugs to treat soil-transmitted helminths (STH), there are human and economic resources required to deliver this intervention at scale. It is critical that policymakers understand these costs and the gains that result from the intervention. Again, the lack of consistent and reliable data on costs from STH control programs precludes an accurate assessment of the relative cost-benefit of deworming as compared to alternative public health interventions [7]. As much as we need to strongly advocate for the continued need to treat children at risk of poor outcomes, we must also recognize that resource