but also for embracing the NTDs to take on what is really a “gang of four.” This concept of integrating NTD control measures with those for malaria and HIV/AIDS will become clearer when we outline possible intervention strategies for NTD control (in chapter 10) and give the reason why we need to consider bundling treatment strategies for the NTDs together with those for HIV/AIDS and malaria (and even possibly why the Global Fund should incorporate NTD control into its programs).Table 1.5 Ranking of the “gang of four” by deaths and DALYsaModified from Hotez et al., 2006a.bModified from Murray et al., 2012.7 The NTDs are stigmatizing. Not surprisingly, the blinding and disfiguring features of NTDs are stigmatizing and cause individuals to be ostracized by their families, their communities, and sometimes even health care professionals.6 In some societies, NTDs are considered a sign of a curse or an “evil eye.” The social stigma of the NTDs strikes young women particularly hard, and as a result, these women are frequently abandoned by their husbands, prevented from holding or kissing their children, or unable to marry altogether. Specific examples of these stigmatizing consequences of the NTDs will be illustrated in the chapters dealing with LF, Buruli ulcer, and leishmaniasis (chapters 4, 6, and 7, respectively).
8 The NTDs have poverty-promoting features and other socioeconomic consequences. The health impact of the NTDs may also represent only the tip of the iceberg in terms of their adverse effects on international development. Because of their chronic and disabling features, the NTDs also produce important and serious socioeconomic consequences that keep affected populations mired in poverty. The NTDs not only occur in the setting of poverty; they also actually promote poverty. For example, the cognitive and intellectual impairments resulting from hookworm-associated iron deficiency and anemia severely affect childhood education in terms of school performance and school attendance. Reduced school attendance leads to reduced future wage-earning capacity, while chronic hookworm infection among agricultural workers has been shown to reduce worker productivity in Africa, Asia, and the Americas. Similarly, LF has a huge impact on productive capacity and costs a significant percentage of India’s gross national product, trachoma causes $5.3 billion in worldwide losses annually, and leishmaniasis is responsible for 0.43% of French Guiana’s social security budget.9 We are only beginning to understand the full economic impact of the NTDs, but these nascent studies indicate that the effects are likely to be profound.
However, even a full consideration of the enormous disability, disfigurement, and economic impact does not adequately convey the total devastation wrought by the NTDs. In an interview with a Sri Lankan LF-affected patient suffering from a severe limb deformity, we can get a palpable sense of the enormous shame and stigma from the limb or genital deformities caused by her disease and how they in turn promote an inexorable slide into poverty.10
I got this big leg when I was engaged to be married. When they heard it was filarial, they backed out of the marriage. I was earning Rs 2,500 (US$25) a month from sewing, but when the leg got worse, the hospital doctor told me I should not pedal the machine. So I lost my income as well. When my parents died and my sister got married, only my brother and I lived in the house. My brother married and left the house, but my sister become widowed so came to live with me and her child. She had no money to buy a bandage as instructed by the clinic. So I went to a house to cook. When they saw my leg, they asked me not to come there anymore and found fault with me for hiding such a dirty illness from them. When I get fever, I cannot walk to the hospital, so I take paracetamol for 2 days and walk to the hospital when I feel less pain.
According to the Sri Lankan health care team investigating such cases of LF, the woman in this vignette, who previously lived on earnings of approximately US$1 per day, lost even this meager income and became totally dependent on her brother-in-law.10 An important theme in the succeeding chapters is how stigma actually contributes to the morbidity of the NTDs and creates not only a medical crisis for the affected individual but also a tragic cycle of social and economic devastation for both the individual and his family. According to Swiss Tropical and Public Health Institute’s Mitchell Weiss, the stigma of the NTDs contributes to suffering, delays the seeking of help, promotes nonadherence to treatment, negatively affects families and communities, and ultimately lessens support for services, control, and research.11 Later, we will even see how, with some of the NTDs such as leishmaniasis, the stigma is particularly acute for young women, often leading to their verbal and physical abuse (in chapter 7), or how the stigma associated with Buruli ulcer is linked to beliefs about witchcraft (in chapter 6).
In summary, the health impact of the NTDs reflects their chronic and disabling features. But there are also educational and socioeconomic consequences that may even be greater. Neglect occurs at many different levels: at the community level because the NTDs arouse fear and inflict stigmas, at the national level because the NTDs occur in remote and rural areas and are often a low priority for health ministers, and at the international level because they are not perceived as global health threats equivalent to the high-mortality big three conditions.12 Paul Hunt, the UN Special Rapporteur on the right to the highest attainable standard of health, points out that relief from the suffering caused by the NTDs is a fundamental human right, which unfortunately has been largely ignored.13 Despite their global importance, we so far have no Bono equivalent to champion the plight of the 1 billion of the world’s poorest people who suffer from NTDs, and the total dollars thus far committed to NTD control are currently measured in the millions, not the billions.
Fortunately, this picture of neglect may one day turn an important corner, in part because of a new resolve by the WHO and national ministries of health, together with several key public-private partnerships dedicated to NTD control. Further, many of the organizations involved in NTD control have begun to partner through a new alliance known as the Global Network for Neglected Tropical Diseases (discussed in chapter 10).14 The Global Network is working to mobilize resources for the NTDs and to promote high-level advocacy from global leaders and celebrities. These activities include a new awareness campaign known as END7 to end seven of the most common NTDs.15 At the same time, student groups are beginning to voice their concerns about the urgency of addressing the NTDs.15 These important, nascent efforts are about to lead to a modest revolution in global health and to make a huge impact on the world’s poorest people.
Summary Points: Introduction to the Neglected Tropical Diseases
The NTDs are among the most common infections of the world’s poorest people, those living on less than US$1.25 per day.
Nonemerging, ancient conditions
Chronic and disabling features
High morbidity, low mortality
DALYs almost equivalent to those for HIV/AIDS, malaria, and tuberculosis
Coendemicity of the NTDs and with HIV/AIDS and malaria
