The Disease Next Door

How the world’s nastiest and least-known outbreaks are afflicting some of the world’s wealthiest countries.

They're probably the most important diseases you've never heard of -- causing everything from greusome limb disfigurement and skin sores to bladder and liver cancers to  neurological damage -- and they're practically ubiquitous among world's poorest people. Typically, such infections last for years or even decades, causing chronic and permanent disabilities such as stunted growth and intellectual developments in children; blindness, heart disease, and disfigurement of adults; and pregnancy complications that can result in severe disease in both newborns and their mothers. In so doing, neglected tropical diseases (NTDs) have been shown to acutally cause poverty and even destabilize communities, leading to conflict.

Because they strike mostly forgotten people living on less than $2 per day, NTDs have traditionally been thought of as a problem exclusive to low-income countries, especially in sub-Saharan Africa (where indeed they are important public health threats). But our latest research shows that most cases of the worst NTDs (defined by disability-adjusted life years lost) actually occur among the extreme poor who live in the large emerging market economies that comprise the G-20, together with Nigeria, which has a GDP equivalent to several Western European countries (See Table).

For example, more than two-thirds of the reported cases of visceral leishmaniasis, which causes a leukemia-like chronic illness, are found in G-20 countries, led by India, Brazil, China, and Italy. Similarly, 60 percent of those who require treatment for lymphatic filariasis, responsible for elephantiasis, live in India, Indonesia, Nigeria, and Brazil; while more than 70 percent of food-borne trematode infections, which cause liver cancer and severe lung disease, are found in China, South Korea, and Russia. Almost two-thirds of the global cases of Chagas disease -- which causes cardiomyopathy and other life-threatening heart diseases -- are in Brazil, Argentina, Mexico, and the United States, and 77 pecent of the world's leprosy cases occur in G-20 countries, led by India, Indonesia, Brazil, and China. Together, the G-20 countries and Nigeria also account for almost half of the world's cases of hookworm infection, while a large number of schistosomiasis cases -- responsible for chronic renal disease, female genital ulcers, and liver disease -- are in Nigeria, South Africa, Brazil, China, and Saudi Arabia.

Much of the disease burden within G-20 countries falls on the poor in Indonesia and the BRICS (Brazil, Russia, India, China, and South Africa), but there are also several serious NTDs found in Eastern and Southern Europe, and in the southern United States, including Chagas disease (heart disease), cysticercosis (seizures and other neuologic illness), and dengue (breakbone fever). New U.S. poverty statistics indicate that today almost 1.5 million American families surive on $2 or less in income per person per day in any given month. Many of the poorest -- and most disease-prone Americans -- reside in Texas and other parts of the Gulf Coast region.

Other locations within the G-20 that are particularly hard hit include areas of extreme poverty in southern Mexico, Saudi Arabia, and the northern territories of Australia (which is heavily populated by aboriginal populations) (See Figure). Instead of thinking of global health in terms of "developing" and "developed," therefore, it makes more sense to conceptualize NTDs as pockets of disease endemicity in areas of intense poverty throughout the world. These pockets occur, of course, in sub-Saharan African and other low-income regions, but they also afflict the world's wealthiest and largest-GDP countries -- countries with enormous financial and scientific capacity to combat and eliminate NTDs.

I refer to this new mapping of global disease burden as "blue-marble health," invoking the iconic 1972 image of Earth taken by the crew of spacecraft Apollo 17. As a potent symbol of the need for global health cooperation, blue-marble health has important policy implications for disease control and science diplomacy. In particular, it has the potential to promote awareness among G-20 countries that NTDs represent a significant impediment to economic development. It also has the potential to encourage international cooperation between G-20 countries to jointly solve thorny NTD problems, while simultaneously galvanizing G-20 support for lower income countries in Africa, Asia, and the Americas.

Since 2007, support from USAID has enabled more than 250 million people in low- and middle- income countries to receive low-cost packages of essential medicines for NTDs -- a practice the World Health Organization (WHO) refers to as "preventive chemotherapy." In 2012, Britain expanded its support of preventive chemotherapy, with shared targets to eliminate NTDs such as lymphatic filariasis, onchocerciasis, trachoma, and leprosy. Beyond Britain and the United States, however, very little is being done to leverage preventive chemotherapy against NTDs. There is an urgent need to encourage all of the G-20 countries (and the Nigerian government) to make similar commitments.

Preventive chemotherapy is considered one of the world's most cost-efficient public health schemes, typically costing less than $0.50 per person annually. Ensuring full G-20 participation in financing preventive chemotherapy for NTDs -- whether it is for their own countries or for less fortunate disease-endemic countries -- should become a high priority for future G-20 summits and discussions. According to the WHO, approximately 1.9 billion people require preventive chemotherapy for NTDs worldwide, yet only about 700 million people (36 percent) currently receive access to essential NTD medicines. Global cooperation among the G-20 and Nigeria is essential for full NTD coverage.

At the same time, the G-20 should take the lead in developing new vaccines and treatments for NTDs. Almost all biotechnology and life-science products are currently developed, manufactured, and tested in G-20 countries, including Brazil, China, India, and Indonesia -- meaning that these countries could take leadership in developing new vaccines specifically for NTDs. Such antipoverty vaccines could target NTDs that can't be treated with preventive chemotherapy alone - such as leishmaniasis and Chagas disease, which cause more than 60,000 deaths per year, and economic losses that exceed $7 billion for Chagas disease alone.

Today, the United States and some European countries account for almost all of the world's public support for neglected disease research and development, with minimal contribution from the emerging market economies of the G-20. As such, there is an urgent need for these other G-20 nations to contribute, especially Russia, India, and China -- countries wich currently spend heavily on nuclear weapons technologies. Their nuclear activities could be redirected for peacetime purposes to develop new NTD technologies.

The recently established U.S. State Department Office of Global Health Diplomacy should lead diplomatic efforts to pressure all of the G-20 countries to expand preventive chemotherapy efforts in order to ensure 100 percent global NTD drug coverage, while simultaneously promoting international scientific cooperation to produce NTD technologies. In some cases, these new scientific activities could be implemented in lieu of nuclear proliferation, similar to joint U.S.-Soviet efforts to collaborate on the development of an oral polio vaccine at the height of the Cold War. Ultimately, blue-marble health could become an important new theme for future G-20 summits as a highly cost-effective means to lift the world's poorest people out of a downward spiral of poverty and conflict.

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Demonstration Effect

Obama shows Netanyahu and Abbas -- and their people -- how it's done.

For all the drama of President Obama's stirring speech Thursday in Jerusalem, the most encouraging thing about it may have been the applause from the audience. "Remarks of President Obama to the People of Israel," the White House called the speech -- and, like President Reagan, Obama went soaring over the heads of officials, elites, and pundits, directly to Israel's citizenry. In that may lie the nub of a second-term approach to Israeli-Palestinian peacemaking that could prove more fruitful than the frustrations of the first.

Conventional wisdom holds that the Israeli-Palestinian conflict is not ripe for resolution -- that Obama should hold back, take the lessons from his failure to spur sustained and constructive peace talks between Israelis and Palestinians, and turn to less painful topics. This is more conventional than wise. Most of the Israeli and Palestinian publics support a two-state solution -- and such a solution is the only viable way out of the conflict ever proposed, going back to the Peel Commission that first recommended partition back in 1937. Benjamin Netanyahu will go down in history as the first Likud prime minister to call for a Palestinian state alongside Israel, thereby irrevocably accelerating Israel's decades-long abandonment of the dream of annexing the biblical heartland of the West Bank. And Palestinian President Mahmoud Abbas and his technocratic prime minister, Salam Fayyad, represent a pragmatic Palestinian leadership that, for all its flaws, has done vastly more to build up the institutions of a future Palestinian state than Yasir Arafat's terrorism and evasions ever did. The United States and Israel are trying to navigate the region's most urgent challenges: Iran's nuclear ambitions, the Assad regime's assault on its own people, and the aftershocks of the 2011 Arab revolutions. The ongoing Israeli-Palestinian conflict offers cheap opportunities for demagogues, extremists, terrorists, and nihilists to exploit.

Much of the early reaction to Obama's speech sprinted to consider modalities and mechanisms -- calling for U.S.-imposed grand designs or fretting about which structure the administration should set up at the State Department. There's time aplenty to get into the weeds. But the president's speech was aimed higher. Obama's approach was not tactical but tectonic, aimed at building sociopolitical momentum behind the forces of a negotiated partition. So long as Netanyahu and Abbas spend their political lives looking over their right shoulders rather than their left, the temptations of stasis will always prove more seductive than the uncertainties of movement. So long as Israeli and Palestinian leaders talk only to their own bases rather than to the other side's public, the comforts of things as they are will always nose ahead of the challenges of things as they could be.

Obama showed them how it's done, with eloquence, empathy, and persuasion. In a spirit of enduring friendship, he did some truth-telling of a sort that the Israeli public does not always get from its leadership -- and his youthful audience roared its approval at a volume that could be heard loud and clear in Ramallah, Nablus, and Gaza City. Obama was both warm and strong, wise and supportive, reiterating yet again that the United States will take no options off the table on Iran even while he reminded Israelis that they and the Palestinians have no options on the table besides a two-state solution or unending occupation, terrorism, and muted and mounting rage.

The president is right: The status quo is not static. The lingering conflict carries ongoing risks to Israeli security. Iran is straining against unprecedented international pressure. Hamas oppresses and impoverishes the suffering people of Gaza. Hezbollah stocks its bristling rocket arsenal to bombard Tel Aviv and Haifa. Settlement expansion is convincing more and more Palestinians that Israel prefers indefinite occupation to preserving its identity as a Jewish democracy. Islamists and jihadists around the region use the enduring conflict as a cudgel to cow voices of moderation and liberalism. And Israel is having its political legitimacy clawed away in international forums, despite the gallant efforts of the Obama administration.

So why delay? After the eruption of another uprising or a nasty mini-war, many Israelis and Palestinians will wish they could take the terms on offer today. Anyone who believes they can confidently predict the regional consequences of another intifada in the era of the Arab Spring has a grave case of intellectual hubris. But there's no need to wait for more blood and tears. What is lacking are not blueprints, maps, or imagination; it is trust and political will. And those can be built and banked by leaders and publics alike.

President Obama has made a fine new start. Now others should follow his example -- finding constructive steps to take in the absence of renewed peace talks that can help foster the presence of renewed peace talks. And there are obvious things all sides can do that do not recapitulate the tactical mistakes of the first term -- by building up public pressure for peace efforts, instilling trust, ripening the spirit of compromise, stripping alibis away from politicians prone to immobilism, and assuaging the legitimate anxieties on both sides that can stop peace talks cold.

Israel could admit the obvious and offer to halt settlement construction outside of the settlement blocs it thinks it may be able to ultimately claim through mutually agreed land swaps with the Palestinians. Israel should crack down -- strongly and demonstratively -- on settlers who indulge in vigilante justice and erode Israel's rule of law. Netanyahu should spell out his vision of the type of Palestinian state he would like to see and remind his base that the old dream of annexing the West Bank has been left behind by the cunning of history. Israel should look for opportunities to dismantle or minimize some intrusions of the occupation into daily Palestinian life, from checkpoint abuses to unnecessary raids into Palestinian-controlled parts of the West Bank. And Israelis of all stripes -- private citizens and public officials alike -- should make clear that they recognize the legitimacy of Palestinian nationalism and rootedness in the land they share, just as they expect the Palestinians to do the same.

The Palestinians should set up a credible process to review their textbooks, insist that Israel is on all their maps, and ensure that both sides of the conflict have their narratives explained in Palestinian classrooms. Abbas should routinely underscore Israel's legitimacy and speak out loudly and clearly against incitement and bigotry against Jews, including the anti-Semitic bilge so regularly spewed forth from Hamas's leaders and enshrined in its charter. Fayyad should continue to find opportunities to show Israelis that Palestinian statehood is about building up responsible, durable institutions to become a peaceful, prospering partner whose very existence enhances Israeli security. Palestinians should prefer the tactics of nonviolent resistance to violent defiance, both because of its efficacy and to convey to ordinary Israelis that their demands are about ending the occupation, not destroying the Jewish state. And the Palestinian leadership should knock off the self-defeating sideshow of marginalizing Israel in U.N. bodies, which only encourages ordinary Palestinians to think that some international cavalry is coming to produce the results that can come only from direct negotiations.

Outsiders can pitch in too -- notably the Gulf states, who often prefer talking a good game about Palestinian statehood to taking uncomfortable steps that might hasten it. Arab leaders should find a way to loudly reiterate and flesh out the bargain implicit in the 2002 Arab Peace Initiative pushed by Saudi King Abdullah -- an end to the Arab-Israeli conflict and "normal relations" with Israel in return for Palestinian statehood and a return to the 1967 lines. Arab states should spell out what those "normal relations" with Israel might look like and paint a vivid and enticing picture for ordinary Israelis of their nation's place in the region on the day after Palestine's negotiated independence. The democratically elected President Mohamed Morsy of Egypt could calm Israeli jitters by getting a better handle on the rising chaos in the Sinai and speaking regularly about Egypt's determination to live up to its treaty obligations. Leaders in Europe, Japan, Canada, and other prosperous countries can publicly vow to underwrite the cost of providing reparations and resettlement for the descendants of the Palestinian refugees who fled their homes during what Israelis call their War of Independence and what Palestinians call the Naqba (or "catastrophe"). And ordinary citizens in Israeli and Palestinian cities alike can embark on dialogue programs like the magnificent Seeds of Peace, which work over time to chip away at old hatreds by reminding people that their identities are about more than the conflict.

Of course, neither Israelis nor Palestinians are out in the streets demanding renewed peace talks right now. But great leaders shape their politics, rather than the other way around. There is plenty that Israelis, Palestinians, and others can do right now to bring peace just a bit closer. Just because things are quiet does not mean that they need to be fallow. And if things become fallow, they will not stay quiet for long.

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