Tropical Diseases Are Keeping Americans in Poverty

Worm infections and other parasites can make people too sick to go to work and can even reduce IQ among kids—yet little attention is being paid to these illnesses, says Dr. Peter Hotez of the Sabin Vaccine Institute.

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Sep 29 2014, 2:44pm

A homeless man in San Francisco. Photo via Flickr user Evan Blaser

The statistics on poverty in America make for sobering reading. The US Census Bureau’s annual report on income shows that one in five American children live in poverty, that Americans are earning less than they did in 2007, and that the median income for black households was about $23,000 less than that of white households. Last year, a report from the National Poverty Center revealed that the number of households in the US living on less than $2 a day per person increased from 636,000 in 1996 to 1.65 million in 2011.

One effect of this kind of poverty is the prevalence of neglected tropical diseases in the US, particularly in the South and along the Gulf Coast, and especially among black and Hispanic communities. Up to 1 million citizens carry the parasite that causes Chagas disease, a chronic infection that leads to deadly heart or gut damage in 40 percent of cases.

There are a number of diseases similar to Chagas that illustrate how impoverished Americans are neglected by society at large. Someone who understands this is Dr. Peter Hotez of the Sabin Vaccine Institute and Texas Children’s Hospital in Houston. He's been working on neglected tropical diseases for his whole life, so I caught up with him to talk about them.

VICE: So the tropical diseases you work on are classed as "neglected"—do you feel that the work you’re doing is also neglected?
Dr. Peter Hotez: There are a group of these diseases. Our original list, which we published in 2005, had 13 or 14 “neglected tropical diseases," and now the World Health Organization has expanded the list to 17, and it’s a good list. I like to call them the most important diseases you’ve never heard of. They’re actually the most common afflictions of poor people. The problem is they’re only occurring among poor people, so there’s no real attention being paid. One of the things that was so powerful for HIV/AIDS was that you had a very strong advocacy group that began in the US, North America, and Europe, and you don’t have that for these diseases, because they’re only occurring among the extremely poor.

One of my studies has shown that some of the highest numbers of neglected tropical diseases are occurring among the poor who live in wealthier countries, including the United States. These are not only the afflictions of sub-Saharan Africa. 

Dr. Peter Hotez

What kind of diseases are popping up in America now that hadn’t before?
Well, it’s not that they hadn’t before; it’s just that nobody was looking, which is also interesting. One of them is called Chagas disease; it’s a parasitic infection of the heart that’s transmitted by the kissing bug, and this is widespread in Texas.

So you think these diseases are ignored specifically because they affect poor people?
That’s right. If these were diseases that were striking the middle class or wealthy people in North America or England, or elsewhere in Europe, we would never tolerate it. But because they’re only occurring among the poorest of the poor they go unseen.

With that in mind, how do you approach working on them?
I guess your question is, "How do you get people to care about these diseases?"

Yeah—how do you get people to care about them, but also how do you get people to care about it without it becoming a situation in which you're putting yourself forward as some kind of savior figure?
Well, one of the things I say is that these diseases not only occur in the setting of poverty; we now also have strong evidence to show that they have caused poverty. Diseases like Schistosomiasis, which is a parasitic worm infection, hookworm, and another one called Toxocariasis—which occurs among the poor in the US—actually reduce intelligence. They reduce IQ among kids, and there are studies to show that when chronic infections occur in childhood [they can] reduce future wage earning by 40 percent. The others make people too sick to go to work.

This is the stealth reason why the bottom billion cannot escape poverty—because they’re too sick. In many cases, we have interventions that are so inexpensive that we could quite easily lift the bottom billion out of poverty through these interventions. In fact, we call the vaccines that we make in our research laboratories "anti-poverty vaccines," because they’re going to have an impact not only on improving health but also on economic development.

Are these vaccines being supported? I suppose the worry is that you tell politicians or big companies that lots of people trapped in poverty have this particular disease, which helps keep them in poverty, and you hear a lot of concerned noises, but then nothing actually happens. As someone working on these diseases, do you feel supported or do you feel occasionally like you’re hitting your head against a brick wall?
I would say both. We have good days and bad days, and we’ve done a reasonably good job of getting donor support from the EU; they’re supporting our hookworm vaccine. The Carlos Slim Health Institute has been supporting our Chagas and Leishmaniasis vaccines. We’ve had support from the Gates Foundation, the US government, and the National Institutes of Health, and another big one is the Michelson Medical Research Foundation. That’s enabled us to develop the vaccines through early stage clinical testing. The challenge is going to be the later stages of clinical testing and leading to licensure—how that’s going to be financed. So we don’t have all the elements of the business model worked out, but we’ve made enormous progress so far in getting these vaccines into clinical testing.

The life cycle of Schistosomiasis (Click to enlarge)

You say that a lot of the solutions for these diseases are really quite simple; is it the case that, with a number of these diseases, you have vaccinations and you have pills, but the issue is about distributing them, about education, about having them find the right people?
Yeah, so this problem is sometimes referred to as global access—how do you ensure global access? And we think we have good strategies in terms of good medicines that we give for de-worming and Schistosomiasis treatment. They seem to be getting to the people who need them. In fact, the US Agency for International Development just celebrated its one-billionth treatment, so people seem to be getting them because they’re fairly simple to use. And that’s how we partly designed the package when we wrote these papers in 2005 and 2006. We thought it would be fairly straightforward and easy, especially when the medicines are being donated and they don't have to be given by a healthcare provider.

How does distribution of these medicines in the US compare with the rest of the world?
The irony is, we’re having a tougher time getting people to accept how widespread neglected tropical diseases are in the US. People don't want to admit that we have poor people in this country, but we have 1.65 million American families living on less than $2 a day. So we’ve been working with Congress to get some legislation enacted. Congressman Chris Smith in New Jersey recently submitted legislation to Congress called the End Neglected Tropical Diseases Act, which addresses the problem not only of NTDs like female genital Schistosomiasis across Africa, but also NTDs here in the US.

So then the presence of NTDs in the US becomes evidence for something that America doesn’t really want to talk about, which is the existence of widespread poverty across the country?
That’s right, and it’s really flared up again now with this immigrant debate—you know, the 50,000 Central American children now being detained at the border of Mexico. One of their rationales for deporting the kids is that they’re going to introduce all these diseases, but in fact the diseases are here and they’ve been here for a very long time. 

I'm always fascinated by the number of American kids who want to go off and “save Africa” but don’t understand that there’s an enormous amount of poverty on their doorstep.
I think the impressive part is the extreme poverty we’re seeing. You know, we now have nearly 20 million Americans living at one half of the US poverty level, and so we’re approaching a level of poverty in this country—mostly in the American South, and then the Gulf Coast—that's reaching the level of poverty of many middle-income countries. It’s poverty that is the overwhelming determinate. We call them “tropical diseases” and sometimes it’s a bit of a misnomer. These are diseases of extreme poverty. I mean, climate is a component, but poverty is the overriding determinant.

Have you seen an upswing in poverty during your time as a doctor?
Well, an upswing in the way that, before, nobody looked, and now we’re looking. So we came to Texas three years ago to create this National School of Tropical Medicine, which is modeled after similar schools in London and Liverpool. The difference is that we’re working in a disease endemic country, which is the southern part of the US and Houston, so that has been very powerful—the idea that we’re making interventions not only for people in Africa, but also for neglected diseases among the poor here at home. The drug companies have been good at donating the medicines, but then it’s another matter to convince their shareholders to invest in research and development to make new interventions that eventually they’d have to give away. So we feel we have to do that in a nonprofit sector.

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