To the extent that middle class and more affluent people think about poverty in America, they likely have blurry, partial images due to distance and lack of direct experience. Their remedies might include better education and training, higher minimum wages, more affordable housing.
New Scientist thinks otherwise. Its headline for a blistering editorial: Want to fix US inequality? Begin with worming tablets.
Reader Francois T, who is a doctor as well as a research scientist, confirms that this piece is as damning as it sounds:
Your first reaction may be: “Worming tablets?? Come on! Tell me this is not about what I think it is!”
Well, sorry to be a Debbie Downer but…Yup! These the ones that, we, doctors, use to cure intestinal parasites so prevalent in so-called third-world countries. Turns out we need to use them here at home too…and a LOT more than anyone cares to admit.
Can there be a more scorching indictment of the sorry state of affairs in this country?
The New Scientist editorial tell President Obama that his checklist for combatting poverty – higher wages and labor bargaining rights, education, social security, and more growth – is incomplete. Readers will also know it’s not serious, since Obama has been trying to weaken Social Security and Medicare, and the Democrats know well unions have nowhere to go, so mere lip service will keep them in the fold. But here is the evidence on how rising inequality is producing even more desperation conditions among the poor:
Something Obama could also have mentioned was buying worming tablets and other remedies for tropical diseases.
This is no joke. Intestinal worms have traditionally been a huge drain on humanity, causing weakness and debilitation and perpetuating poverty. Nowadays such parasites are mainly a problem in Africa and Asia. But millions of the poorest people in the US also have worms – and they perpetuate poverty there, too.
It isn’t just worms. A dozen chronic parasitic diseases that plague the tropical poor also plague people in the US …They include Chagas disease, a relative of Africa’s sleeping sickness, and dengue, which has lately been spreading within the US…
Most of these diseases are easy to prevent and cure. They are linked to poor sanitation, lack of basic medical care and homes infested with vermin – all of which are associated with poverty.
And poverty is growing: the percentage of US homes living on less than the World Bank’s threshold of $2 per person per day has doubled since 1996. Some 20 per cent of all households with children get by on that or less at least sometimes.
Chagas? I first heard about it in Texas about a year ago. The person who gave me an earful has a doctor for a brother, and gave an alarmed reading on how quickly it was spreading (although he was also inveighing on illegal immigration, as opposed to poverty, as the culprit).
Chagas is nasty and pretty much never diagnosed. From a second New Scientist article, America’s hidden epidemic of tropical diseases:
When the letter arrives, it must come as a shock. Would-be blood donors are politely rejected because they’ve tested positive for a deadly tropical infection – and their doctors aren’t much help. Kristy Murray at Baylor College of Medicine in Houston, Texas, recalls one doctor telling a patient: “The test is wrong. That disease doesn’t exist in the US!”
But an estimated 330,000 US citizens, and possibly as many as a million, carry the parasite that causes Chagas disease. It is a chronic, silent infection that leads to lethal heart or gut damage in 40 per cent of cases. It is the most common parasitic disease in the Americas, and it can be treated – if the doctor is aware of it. Most US doctors aren’t.
Revealingly, Wikipedia is out of date on the status of chagas in the US, but it does give a good (as in grim) overview of how it spreads:
Chagas disease is contracted primarily in the Americas, particularly in poor, rural areas of Mexico, Central America, and South America; very rarely, the disease has been found in the Southern United States…Large-scale population movements from rural to urban areas of Latin America and to other regions of the world have increased the geographic distribution of Chagas disease…
In Chagas-endemic areas, the main mode of transmission is through an insect vector called a triatomine bug.A triatomine becomes infected with T. cruzi by feeding on the blood of an infected person or animal. During the day, triatomines hide in crevices in the walls and roofs. The bugs emerge at night, when the inhabitants are sleeping. Because they tend to feed on people’s faces, triatomine bugs are also known as “kissing bugs”. After they bite and ingest blood, they defecate on the person. Triatomines pass T. cruzi parasites (called trypomastigotes) in feces left near the site of the bite wound.
An article in Austin CERT explains why it often goes undiagnosed:
Chagas can be hard to detect because it can look like the flu at first, with symptoms similar to pains and fever. The symptoms appear to go away but the disease can live in a person for decades, sometimes reappearing in the form of digestive or heart failure.
In Texas, where most doctors are not familiar with the disease and are not required to report it to public health officials, they may misinterpret its late-onset symptoms as an old age problem…
And I’m taking the liberty of providing a lengthy excerpt from a widely-cited 2012 article that compares chagas to HIV:
Neglected tropical diseases (NTDs) are among the most common conditions afflicting the estimated 99 million people who live on less than US$2 per day in the Latin American and Caribbean (LAC) region ….With approximately 10 million people living with Chagas disease, this condition is one of the most common NTDs affecting the bottom 100 million in the region, a prevalence exceeded only by hookworm and other soil-transmitted helminth infections , . Moreover, among the NTDs in the Americas, Chagas disease ranks near the top in terms of annual deaths and DALYs [disability-adjusted life years] lost , …
Among those living with Chagas disease around the world today, 20%–30% (roughly 2–3 million people) are either currently suffering from Chagasic cardiomyopathy or will develop this clinical sequela . Chagasic cardiomyopathy is a highly debilitating condition characterized by cardiac arrhythmias, heart failure, and risk of sudden death from ventricular fibrillation or tachycardia or thromboembolic events . Another estimate suggests that up to 5.4 million people living today will develop Chagasic cardiomyopathy , . Damage to the gastrointestinal tract can also produce debilitating megaesophagus and megacolon .
There are a number of striking similarities between people living with Chagas disease and people living with HIV/AIDS, particularly for those with HIV/AIDS who contracted the disease in the first two decades of the HIV/AIDS epidemic. Both diseases are health disparities, disproportionately affecting people living in poverty , . Both are chronic conditions requiring prolonged treatment courses: a lifetime of antiretroviral therapy for HIV/AIDS patients, and one to three months of therapy for those with Chagas disease . Treatment for HIV/AIDS is lifesaving, although it seldom if ever results in cure, while for Chagas disease, the treatment has proven efficacy only for the acute stages of the infection or in children up to 12 years of age during the early chronic phase of the infection . For both diseases the treatment is expensive—in the case of Chagas disease, the expected cost of treatment per patient year is $1,028, with lifetime costs averaging $11,619 per patient.
New Scientist says that American doctors can get the drugs to treat chagas only by applying directly to the FDA.
And chagas isn’t the only so-called “neglected tropical disease” on the march in the US. Despite the name, these are aliments of poverty, not geography. For instance, for chagas, comparatively simple measures such as encouraging people to store wood away from their homes, encouraging living in concrete rather than wood or adobe structures, and selective pesticide spraying have reduced disease incidence considerably. But consider this depressing recap from New Scientist:
The more researchers look for these diseases, though, the more they find. In 2008, [Peter] Hotez [of Baylor College of Medicine] made initial calculations of the number of cases in the US for several NTDs, most of which still stand as the best estimates available. Updated work on two parasites, however – Trichomonas vaginalis and Toxoplasma gondii – shows that many more people have the infections than was thought five years ago. Much is specific to minority communities: 29 per cent of black American women carry T. vaginalis, versus 38 per cent of women in Nigeria. In the US, black women are 10 times as likely as white or Hispanic women to have the parasite, which increases the heterosexual spread of HIV and boosts the risk of a low-birthweight baby. Highly sensitive diagnostic tests were recently developed, and trichomoniasis can be cured with one oral dose of a common drug, metronidazole. But the startling prevalence of the disease suggests neither test nor treatment is routinely used…
Hispanic people in the US are also more likely to ingest eggs of the pork tapeworm, shed in human faeces, which can cause epilepsy if they lodge in the brain. Called cysticercosis, this now causes 1 in 10 seizure cases taken to Los Angeles emergency rooms. Poor white people in Appalachia, meanwhile, suffer from the intestinal threadworms Strongyloides stercoralis and Ascaris lumbricoides, a leading global cause of impaired childhood development.
The mosquito-borne dengue fever virus was chased from the US by DDT spraying in the 1950s, but is making a comeback. This year [Kirsty] Murray [of Baylor College of Medicine] found that dengue is being transmitted in Houston. Next year she will start testing random hospital patients for antibodies to see how widespread it is
Neither the Administration nor Congress so far has not roused itself to take interest in and fund even data collection on the incidence of NTDs. And it’s not as if poverty-linked diseases stay neatly contained in low-income ghettos. Consider, for instance, this 2012 report from the Palm Beach Post, Worst TB outbreak in 20 years kept secret:
The CDC officer had a serious warning for Florida health officials in April: A tuberculosis outbreak in Jacksonville was one of the worst his group had investigated in 20 years. Linked to 13 deaths and 99 illnesses, including six children, it would require concerted action to stop…
As health officials in Tallahassee turned their focus to restructuring [aka shrinking the Department of Health], Dr. Robert Luo’s 25-page report describing Jacksonville’s outbreak — and the measures needed to contain it – went unseen by key decision makers around the state. At the health agency, an order went out that the [Lantana] TB hospital must be closed six months ahead of schedule.
Had they seen the letter, decision makers would have learned that 3,000 people in the past two years may have had close contact with contagious people at Jacksonville’s homeless shelters, an outpatient mental health clinic and area jails. Yet only 253 people had been found and evaluated for TB infection, meaning Florida’s outbreak was, and is, far from contained.
Predictably, Obamacare provides for free preventive care like blood pressure tests, flu shots, mammograms, and obesity counseling, while expected to 30 million uninsured, many of whom will fall in these at risk categories. Enriching Big Pharma and health insurers was more important than addressing festering public health problems that perpetuate poverty and create conditions for the spread of contagions into the population at large.
But this is the world that neoliberalism creates: widening income disparity and falling levels of social well-being, particularly poorer health, even among the wealthy. Unless the rich decide to embrace these diseases as causes, as Bill Gates has of malaria (and Carlos Slim is taking an interest in chagas), the policy elites appear to prefer to sweep this indictment their new world order under the rug as long as the possibly can, even if the neglect is to their detriment.
Update 6:00 PM: Reader Francois T adds by email:
People won’t be treated for Chagas in the US because unless one has a high index of clinical suspicion, no one will look for it. Now, give me a Brazilian or Peruvian-trained doctor now practicing in the US and voila!
As for treatment, I will let the excellent Mayo Clinic Web reference take it away:
Treatment for Chagas disease focuses on killing the parasite and managing signs and symptoms.
During the acute phase of Chagas disease, the prescription medications benznidazole and nifurtimox may be of benefit. Both drugs are available in the regions most affected by Chagas disease. In the United States, however, the drugs can be obtained only through the Centers for Disease Control and Prevention.
Once Chagas disease reaches the chronic phase, medications aren’t effective for curing the disease. Instead, treatment depends on the specific signs and symptoms:
• Heart-related complications. Treatment may include medications, a pacemaker or other devices to regulate your heart rhythm, surgery, or even a heart transplant.
• Digestive-related complications. Treatment may include diet modification, medications, corticosteroids or, in severe cases, surgery
This is why I was so shocked by the NS article. Letting Chagas run rampant is the stupidest idea one can think of in terms of public health, unless we are willing to let people die in the streets without care.