This week, the anniversary of Hurricane Katrina, is always a time for me for reflection on poverty and justice in America. Katrina brought focus to our country’s disparities and the response—or lack thereof—to disasters. And now, ironically on the anniversary of Katrina, Hurricane Isaac struck New Orleans again.
Even prior to the Hurricane, in 2005, the Gulf States (Louisiana, Mississippi, and Alabama) had a high level of poverty, as did large pockets in Texas.
The figures on poverty in the U.S. are staggering. In America, 20 million people live in extreme poverty, defined as families with incomes that are less than half of the federal poverty level, and “2.8 million children are living in households with incomes of less that $2 per person per day.” This seems to be a dramatic failure of “compassionate conservatism”, as well as of subsequent public policy. Income levels like these are what are found in “Fifth-World” countries – countries that lack the resources to provide for their citizens and that often have extreme disease burdens in their citizenry.
Such levels of poverty are not only unconscionable but are, pragmatically speaking, poor public policy. This level of poverty exacts an enormous burden on the U.S. and inhibits our ability to advance and maintain a strategic edge.
Currently more than 40% of African American children in the Gulf States currently live in poor families, with over 12% of children from Louisiana and Mississippi living in extreme poverty, according to the National Center for Children in Poverty at Columbia University.
While we commonly think of “Neglected Tropical Diseases” as occurring in Africa, Southeast Asia, and South America, the rates of some of these neglected infections in the U.S. are comparable to those in Nigeria—the country most burdened by NTDs—particularly for helminth (worm) infections. More exotic, insect-borne infections are also increasing in the South, likely from a combination of poverty, poor living conditions, and climate change. These include Chagas disease (transmitted by triatomine or kissing bugs), leishmaniasis (transmitted by sandflies), and dengue (transmitted by mosquitoes). There is also currently an outbreak of mosquito-borne West Nile virus in Texas.
In the U.S., the NTDs tend to be clustered among the poor along the Gulf Coast states, Indian Reservations, and Appalachia. Many of these infections not only affect the poor disproportionately, but are also poverty promoting in and of themselves. For example as Dr. Peter Hotez has noted, helminth infections cause anemia, stunting, and learning difficulties, which leads to school absenteeism and lower economic productivity, furthering the cycle of poverty.
Many of the NTDs are found in the Gulf Coast states because of the climate, but they also thrive there because of large areas where sanitation is poor. Dilapidated housing further exposes populations to insect-transmitted diseases. According to the Katrina Pain Index, by Loyola professors Bill Quigley and Davida Finger, “Seventy percent more people are homeless in New Orleans since Hurricane Katrina. People living with HIV are estimated to be homeless at 10 times the rate of the general population, a condition amplified after Hurricane Katrina.” If does nothing else, homelessness certainly exposes people to insect borne diseases.
These NTDs are often overlooked. Even I, an infectious diseases physician, was only peripherally aware of them until 2006, when I first heard Dr. Hotez speak, and then specifically sought out training in tropical infectious diseases. While my medical school education covered considerable esoterica and there was a fine infectious diseases department at my school, these parasites were barely mentioned. There is a significant need for increased education about these diseases for medical school students and primary care physicians, especially, as the prevalence of NTDs continues to increase throughout the country.
One of the many consequences of Hurricane Katrina was serious disruption of the already overburdened “safety-net” hospitals and clinics in New Orleans; the number of such clinics dropped from 90 to 16. There already was a higher rate of uninsured residents than average (21 vs. 18%). Charity Hospital provided the bulk of the indigent care; it was closed because of the hurricane. The number of physicians dropped from ~4486 to 1200.
I would imagine that most practicing physicians, especially those in harried primary care settings, are not attuned to looking for these infections. They are also likely to overlook them, because with busy staff and overcrowded clinics, the priorities would be, appropriately, to focus on acute symptoms and illnesses such as diabetes, hypertension, and asthma. However, the chronic, longer-term consequences of persistent infection with NTDs is devastating, particularly to a child whose body is trying to grow and develop.
Similarly, as state and local budgets are being slashed, public health departments will have fewer resources to focus on these problems. According to Hotez, helminth infections in the U.S. were last studied in the late 1970s. At that time, they were “highly prevalent in southern Louisiana (Lafayette, Baton Rouge, and Independence, Louisiana), especially among African Americans…Toxocariasis, a helminth infection transmitted from dogs and cats, is likely the most common helminth infection in the US, with a prevalence among African Americans that exceeds 20%, especially in the South.” Ascaris was still endemic in Appalachia in the late 1970s, infecting ~14% of children; it, too, has not been studied since then. Hotez further notes that data on neglected diseases of poverty in Washington, D.C., our nation’s capitol, are almost non-existent.
So what kinds of infections will we increasingly see in the Gulf states?
First, we can expect to see diseases that are associated with poverty, which therefore disproportionately affect African-Americans (2.8 million with toxocariasis alone) and Hispanic Americans (e.g., Chagas and cysticercosis).
Those specifically associated with poor housing, lack of air conditioning or adequate screens include:
In particular, poor sanitation/standing water will also serve as breeding grounds for mosquitoes, resulting in increased risk of dengue (via Aedes aegypti mosquito). In the last 10 years, dengue began to appear along the Texas-Mexico border; since 2009, it has been seen in Florida for the first time since 1934. Although practicing now in the mid-Atlantic, I’ve seen 2 patients in the past year with dengue acquired from the Florida area.
For much of our history, malaria was endemic in the U.S.; it was eradicated by 1951 after intensive use of pesticides (DDT) and wetland drainage—which brought their own problems. Interestingly, the impetus for the eradication efforts was to enhance the World War II training efforts. In 1932, the Office of Malaria Control in War Areas was established to reduce malaria and vector-borne infections, such as murine typhus, which were interfering with military base training exercises.
Will malaria make a resurgence along with West Nile virus, which is also spread by mosquitoes? I suspect that it will.
We should also expect to see these NTDs associated with poor sanitation or soil transmission:
These infections are all most common among the poor, and tend to lead to a self-perpetuating cycle of less education and worsening poverty. Those affected are marginalized. They have no lobbying power. And soon they won’t be able to vote…
In an upcoming post, we’ll look at drugs for neglected diseases.
In the meanwhile, do we really need to wait for these diseases to become endemic once again, permanently stunting the growth and development of an entire generation of Americans? Or should we take action now – focusing on the elimination of these diseases as a way to alleviate poverty and improve the chances of future generations of Americans to thrive and prosper. . .How can you help? Learn more by contacting:
Hurricane Katrina image - NASA/Wikipedia
Katrina evacuees at Superdome - Houstonia/Flickr
Poverty map - Census bureau
Infections of Poverty-Geographic Clusters - PLoS Neglected Tropical Disease pntd.0000256.g00
Chart: Prevalence of Neglected Infections of Poverty - PLoS Neglected Tropical Disease pntd.0000256.g00
Malaria map - CDC
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