Forgotten People Forgotten Diseases:
The Neglected Tropical Diseases and Their Impact on Global Health and Development, Second Edition
Editor:
Peter J. Hotez1
Category: General Interest
Forgotten People Forgotten Diseases is now available on Wiley.comMembers, use the code ASM20 at check out to receive your 20% discount.
The neglected tropical diseases (NTDs) are the most common infections of the world’s poor, but few people know about these diseases and why they are so important. This second edition of Forgotten People, Forgotten Diseases provides an overview of the NTDs and how they devastate the poor, essentially trapping them in a vicious cycle of extreme poverty by preventing them from working or attaining their full intellectual and cognitive development.
Author Peter J. Hotez highlights a new opportunity to control and perhaps eliminate these ancient scourges, through alliances between nongovernmental development organizations and private-public partnerships to create a successful environment for mass drug administration and product development activities. Forgotten People, Forgotten Diseases also:
- Addresses the myriad changes that have occurred in the field since the previous edition.
- Describes how NTDs have affected impoverished populations for centuries, changing world history.
- Considers the future impact of alliances between nongovernmental development organizations and private-public partnerships.
- Forgotten People, Forgotten Diseases is an essential resource for anyone seeking a roadmap to coordinate global advocacy and mobilization of resources to combat NTDs.
“Like Dr. Hotez, I have struggled with how to best get the word out about our need to address NTDs and their link to poverty. Now he has provided us all with a remarkable tool, a book for people without an extensive scientific or medical background. Forgotten People, Forgotten Diseases is an excellent “one-stop” primer about NTDs”
─ From the Foreward by Soledad O’Brien
Peter J. Hotez, MD, PhD, is the founding Dean of the National School of Tropical Medicine and Professor of Pediatrics and Molecular Virology & Microbiology at Baylor College of Medicine. He is also President of the Sabin Vaccine Institute; Director of the Texas Children’s Hospital Center for Vaccine Development; Texas Children’s Hospital Endowed Chair of Tropical Pediatrics; and Baker Institute Fellow in Disease and Poverty at Rice University.
Paperback, 274 pages, biographical references, index.
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Chapter 1 : Introduction to the Neglected Tropical Diseases: the Ancient Afflictions of Stigma and Poverty
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Abstract:
The health impact of the neglected tropical diseases (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. 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. The world’s most influential finance ministers and policymakers have begun to regard improvements in global health as an important tool for poverty reduction.
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Chapter 2 : “The Unholy Trinity”: the Soil-Transmitted Helminth Infections Ascariasis, Trichuriasis, and Hookworm Infection
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The neglected tropical diseases (NTDs) are the most common infections of the world’s poorest people, and the soil-transmitted helminth (STH) infections are the most common NTDs. The three most important STH infections of humans, based on their prevalence and global disease burden, are: (i) Ascaris infection (also known as roundworm infection or ascariasis); (ii) hookworm infection (hookworm); and (iii) Trichuris infection (whipworm infection or trichuriasis). Together, these helminth infections afflict more than 1 billion people in developing countries. The intestines of hundreds of millions of children living in Africa, Asia, and the Americas harbor a menagerie of worms. Harold Brown, the late former parasitology professor at Columbia University College of Physicians and Surgeons, frequently referred to Ascaris, Trichuris, and hookworms as “the unholy trinity” to indicate that it was extremely common for a child to be infected with all three parasites simultaneously. In addition to their enormous global prevalence and their intimate link with rural poverty, another important feature of STH infections is their predilection for affecting children more than adults. The unholy trinity adversely affects the neuropsychiatric activities of children, in turn damaging school performance and reducing school attendance. Currently, the most effective approach to the control of STH infections is through deworming of large populations through mass drug administration of anthelmintic drugs belonging to the benzimidazole class (sometimes referred to as benzimidazole anthelmintics or BZAs).
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Chapter 3 : Schistosomiasis (Snail Fever)
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Schistosomiasis is a waterborne parasitic worm infection affecting up to 400 to 600 million people in developing countries. Humans acquire schistosomiasis by direct contact with the larval stages (known as cercariae) that swim in freshwater. Prior to becoming cercariae, the immature developing and reproducing forms of these parasites spend a part of their life history living in various species of aquatic snails. Children and adolescents are at highest risk. All forms of chronic schistosomiasis are associated with anemia, undernutrition and growth impairments, poor school performance, and reduced productive capacity. Urogenital schistosomiasis caused by Schistosoma haematobium accounts for approximately two-thirds of the schistosome infections in Africa. This form is responsible for hematuria, female genital schistosomiasis, and squamous cell carcinoma of the bladder. Genital lesions increase the risk of HIV/AIDS transmission. Intestinal and liver schistosomiasis caused by S. mansoni accounts for approximately one-third of the cases in Africa and 1 million cases of schistosomiasis in Brazil. This form is responsible for bloody diarrhea, abdominal pain, and liver involvement (hepatomegaly and fibrosis). The major approach to control of schistosomiasis today is mass drug administration of praziquantel. It has led to the near elimination of schistosomiasis in some middle-income countries and to significant morbidity reductions in some sub-Saharan African countries.
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Chapter 4 : The Filarial Infections: Lymphatic Filariasis (Elephantiasis) and Dracunculiasis (Guinea Worm)
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Elephantiasis is the most severe and dramatic complication of lymphatic filariasis (LF), a chronic infection caused primarily by the filarial parasite Wuchereria bancrofti. Dracunculiasis is another chronic infection caused by a filaria-like parasite, Dracunculus medinensis, also known as the guinea worm. Although both LF and dracunculiasis are still important public health problems in the developing world, we are much farther along in our global efforts to control these ancient scourges. For LF, ivermectin, diethylcarbamazine (DEC), and albendazole are donated free of charge. Therefore, LF mass drug administration can be provided for less than US$1 per person. Similarly, the estimated cost of the Dracunculiasis Eradication Program (DEP) between 1987 and 1998 was $87.5 million, or approximately US$5 to $8 per prevented case. In their own ways, LF mass drug administration and the DEP have been wildly successful. Given dramatic rates of guinea worm reduction over the last 25 years and now the stepped-up measures in Sudan through a new Sudan Guinea Worm Eradication Program, there is optimism about achieving these goals. Major reasons for success include the availability of simple interventions together with President Carter’s high-level advocacy and excellent coordination by the Carter Center and its partners. For LF, wherever elimination efforts have been aggressively pursued, the outcome has been extremely favorable.
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Chapter 5 : The Blinding Neglected Tropical Diseases: Onchocerciasis (River Blindness) and Trachoma
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This chapter talks about the impact of blindness that results from two neglected tropical diseases (NTDs) that are entirely preventable with simple, safe, and effective preventive chemotherapy. Onchocerciasis is a parasitic helminth infection occurring in an estimated 20 to 30 million people, primarily in West and Central Africa. Onchocerciasis is also known as river blindness because the Simulium blackflies that transmit this filarial infection breed along fast-flowing streams. The infection is caused by Onchocerca volvulus, a filarial worm mostly migrate in the skin, where it causes intense itching and disfigurement. Onchocerciasis also produces a serious, debilitating, and stigmatizing skin disease (OSD). The Onchocerciasis Control Program (OCP) has helped to facilitate the elimination of onchocerciasis in large regions of 11 West African countries. Trachoma is a bacterial infection occurring in approximately 20 million persons living in the developing regions of Africa, the Middle East, Central Asia, India, and Southeast Asia. The infection is spread from person to person on dirty hands and clothing, but it is also carried by flies, which can carry the Chlamydia bacteria from the eye discharges of one person to another. A breakthrough in the global control of trachoma was the discovery that a single dose of azithromycin was as effective as 4 to 6 weeks of topical tetracycline.
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Chapter 6 : The Mycobacterial Infections: Buruli Ulcer and Leprosy
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Mycobacteria are slim bacteria with unusual growth requirements and unique structural and biochemical properties that place them in their own category of microorganisms. Tuberculosis (TB), caused by the bacterium Mycobacterium tuberculosis, is the best-known mycobacterial infection of humans. Buruli ulcer and leprosy are two highly disfiguring and stigmatizing neglected tropical diseases (NTDs) that occur almost exclusively among the impoverished living in developing countries. Buruli ulcer is a highly disfiguring skin infection caused by M. ulcerans. Buruli typically strikes school-age children and manifests as a large ulcer usually appearing on the limbs. The ulcer of Buruli disease has a number of catastrophic consequences for the patient, including a profound socioeconomic impact and the widespread belief that witchcraft and curses play an important role in transmitting the disease. The most effective treatment of large ulcers requires access not only to antibiotics but also to different surgical modalities, including skin grafting. Leprosy (also known as Hansen’s disease) is caused by M. leprae. Leprosy proceeds along either one of two clinical courses. The majority of patients develop the so-called tuberculoid form. Such patients have the ability to mount strong immunological responses against M. leprae and, as a result, develop only localized disease. Far more severe is the lepromatous form of leprosy. These patients experience widely disseminated disease in the skin and nerves and even the eyes, nose, mouth, and bones. The most widely used multidrug therapy (MDT) drug regimen calls for dapsone to be administered together with the antibacterial drugs rifampin and clofazimine.
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Chapter 7 : The Kinetoplastid Infections: Human African Trypanosomiasis (Sleeping Sickness), Chagas Disease, and the Leishmaniases
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The kinetoplastid infections are transmitted by insect vectors, and the three major kinetoplastid infections of humans, human African trypanosomiasis (HAT), Chagas disease, and leishmaniasis, kill approximately 70,000 people annually, making them among the most lethal neglected tropical diseases (NTDs). HAT, also known as sleeping sickness, is caused by two different species of trypanosomes. Trypanosoma brucei gambiense is the cause in West Africa, while T. b. rhodesiense occurs in East Africa. It results from the bite of tsetses of the genus Glossina. Control of West African HAT relies largely on case detection and treatment as well as vector control, while fighting East African HAT relies on control in animal reservoirs and vector control. Chagas disease, also known as American trypanosomiasis, is caused by T. cruzi, which has the ability to invade host cells and replicate as amastigotes. The infection is transmitted by kissing bugs, primarily of the genus Triatoma. Control of Chagas disease in the Southern Cone has been highly effective through indoor spraying that targets the vector, T. infestans. Leishmaniasis is transmitted by the bite of a sandfly. Cutaneous leishmaniasis (CL) is a disfiguring, pizza-like lesion, which often self-heals but can leave a scar. The scar is often deeply stigmatizing for women in developing countries. Visceral leishmaniasis (VL), or kala-azar, produces a febrile wasting syndrome with signs and symptoms that resemble leukemia. Drugs containing antimony are still widely used for the treatment of CL and VL, but are toxic and difficult to administer.
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Chapter 8 : The Urban Neglected Tropical Diseases: Leptospirosis, Dengue, and Rabies
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The neglected tropical diseases (NTDs) leptospirosis, dengue, and rabies have particular importance as urban health problems in developing countries. Leptospirosis is one of the world’s most common zoonoses, transmitted through contact with bodies of water, such as canals and sewers, contaminated with leptospires. In urban areas, contamination occurs through exposure to the urine of rats and stray dogs, which teems with leptospires. Adequate prevention requires having an intact system of surveillance and case detection as well as environmental control. Dengue fever is one of the most common NTDs of urban areas, and the number of dengue cases is expected to rise as a consequence of increasing urbanization and global warming. Dengue is caused by a single-stranded RNA flavivirus and transmitted by the bite of a female Aedes mosquito. A. aegypti is the most common insect vector species. The most feared complication of dengue is dengue hemorrhagic fever (DHF), which is associated with severe morbidity. No vaccine is yet available for dengue, and public health control relies on labor-intensive practices of environmental vector control. Approximately 50,000 people die from rabies annually. Most of these deaths occur as the result of stray-dog bites in developing countries. There is also an enormous economic toll from rabies. This is because of the need to administer postexposure prophylaxis (PEP) with rabies vaccine to almost anyone bitten by a dog in developing countries. The public health control of rabies in many countries has been achieved through aggressive campaigns to vaccinate dogs in urban centers.
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Chapter 9 : The Neglected Tropical Diseases of North America
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Today, the persistence of the neglected tropical diseases (NTDs) in North America, considered one of the world's wealthiest continents, represents a health disparity of astonishing proportions. The major U.S. NTDs include soil-transmitted helminth infections, especially toxocariasis and strongyloidiasis and cysticercosis, the neglected protozoan infections toxoplasmosis and Chagas disease, and the neglected bacterial and viral infections such as dengue. Cysticercosis may be the single leading cause of epilepsy in the southwestern United States, and toxoplasmosis is a major cause of birth defects. The Inuit of the Canadian Arctic and Alaska also suffer from several NTDs, including toxoplasmosis, trichinellosis, and echinococcosis. Several NTDs, including onchocerciasis, soil-transmitted helminth infections, trachoma, and cutaneous leishmaniasis (CL), occur frequently in rural southern Mexico, especially in Chiapas, and Chagas disease is still focally endemic. Schistosomiasis and lymphatic filariasis (LF) remain serious endemic NTDs in the Caribbean. Many of these NTDs could be easily controlled or eliminated and at relatively modest cost. The most immediate need is to support studies in order to better assess the true prevalence of these infections and then to identify simple and cost-effective public health solutions.
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Chapter 10 : The Global Network for Neglected Tropical Diseases
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The neglected tropical diseases (NTDs) are among the leading disabling conditions of humankind. According to one estimate the NTDs result in 56.6 million disability-adjusted life years (DALYs ), i.e., the number of healthy life years lost from disability or premature death) lost annually. Mass drug administration (MDA) has been effective against NTDs. The World Health Assembly (WHA) has adopted a number of ambitious resolutions over the years to promote the use of MDA for NTDs. In order to raise awareness about the NTDs and the promise of integrated NTD control, the Global Network for Neglected Tropical Diseases was established by the Sabin Vaccine Institute in 2006 to work with the health ministries in countries where the diseases are endemic. It focuses its activities primarily on advocacy, resource mobilization, bilateral engagement (parliaments and ministries of health), and international development banks in order to achieve the overall goal of increasing access to essential medicines for the estimated 1.4 billion people affected by the major NTDs targeted through preventive chemotherapy. Doing so would improve childhood development, school attendance and performance, pregnancy outcomes, and worker productivity among the world’s poorest populations. Integrated control of the NTDs is under way in at least seven sub-Saharan African countries.
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Chapter 11 : Future Trends in Control of Neglected Tropical Diseases and the Antipoverty Vaccines
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With an ambitious global agenda to scale up integrated interventions for more than 1 billion people living in 56 developing countries where multiple neglected tropical diseases (NTDs) are coendemic, we need to carefully consider the specter of resistance and other forms of drug failure. Of the six possible different drugs contained in the rapid-impact package—azithromycin, praziquantel, albendazole or mebendazole, and diethylcarbamazine or ivermectin—the agents albendazole and mebendazole particularly stand out as drugs that could induce resistance. To create a truly robust pipeline of NTD drugs, we need to look to either small biopharmaceuticals or a new generation of NTD product development partnerships (PDPs). Many of the NTD PDPs are funded in part by the Bill & Melinda Gates Foundation. With genomes completed for a large number of NTD pathogens, including the agents that cause Chagas disease, human African trypanosomiasis, leishmaniasis, leprosy, leptospirosis, lymphatic filariasis (LF), schistosomiasis, and trachoma, it should be theoretically possible to mine bioinformatics databases in order develop a large number of antipoverty vaccines in the coming decade. The global control and elimination of the NTDs will require mechanisms to introduce new health products, e.g., vaccines, drugs, and diagnostics, together with existing drugs, in order to create new-generation rapid-impact packages. This approach will be necessary for sustainably reducing poverty and for meeting Millennium Development Goal targets.
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Chapter 12 : Repairing the World
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A global assault on the NTDs through both widespread deployment of rapid-impact packages and the simultaneous development and implementation of new control tools could one day become a highly productive application of medical science and public health for repairing the world. The control and elimination of the NTDs may also provide added global benefit in light of the underappreciated link between NTDs and human conflict. The examples of human African trypanosomiasis (HAT), onchocerciasis, lymphatic filariasis (LF), Chagas disease, and leishmaniasis illustrate an intimate link between the NTDs and long-standing conflict. The common features of this relationship include reductions in public health control programs because of violence and a shifting of limited resources in favor of military spending and buildup. A new government-academic- industrial enterprise devoted to NTDs can offer an unprecedented new opportunity for reducing global poverty and repairing the world. We have in hand today an extraordinary toolbox of highly effective preventive chemotherapeutic drugs and the technological capacity to build a new generation of drugs and vaccines. We have a win-win opportunity to control and eliminate humankind’s major NTDs and need to act in a timely manner and with great efficiency.
There are no separately available contributors for this publication.
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I, Science
13 February 2015
As Dr Peter Hotez notes in the second edition of Forgotten People Forgotten Diseases, thanks to the Millennium Development Goals we are witnessing a new sense of urgency about the suffering of the world’s poorest people. The MDG 6, to “combat HIV/AIDS, malaria, and other diseases”, has been a target for funds from celebrities, philanthropic organizations and G8 nations. But while HIV/AIDS, malaria and tuberculosis have received unprecedented levels of interest, there remains a group of diseases that still sit on the sideline. This is a group of exotic-sounding tropical infections that Hotez, a paediatrician and global health advocate, sees as representing “a health and socioeconomic problem of extraordinary dimensions”.
These are the neglected tropical diseases (NTDs), so named because they are just that – neglected. Testament to his distinction as Dean of the National School of Tropical Medicine and President of the Sabin Vaccine Institute, Hotez unleashes his wealth of knowledge in this book on the 17 NTDs identified by the WHO – a list that spans ascariasis to Wuchereria bancrofti. As somebody who has tried to find information on these diseases in the past, I know that it is a challenge to obtain up-to-date, complete information about the NTDs and their respective eradication efforts. But Forgotten People Forgotten Diseases provides exactly that ‘one-stop’ resource.
This book is comprehensive yet extremely readable, and is meticulously well referenced. It includes numerous colour pictures, maps and simplified diagrams of complex pathogen life cycles. The brilliant summary tables throughout the book present the information in a format that’s easy to read. And even if you just want a basic overview of a condition, Hotez concludes each chapter with summary points that highlight the key bits of information. The book is well structured, with related diseases placed together in the same chapter. Covering soil-transmitted helminth infections, schistosomiasis, filarial infections, blinding diseases, mycobacterial infections, kinetoplastid infections, leptospirosis, dengue, rabies and the neglected tropical diseases of North America. Hotez’s broad-ranging book spans numerous diseases across multiple continents.
The final chapters are on the future trends for controlling NTDs. Here, Hotez details how pharmaceutical companies and advocacy organizations might work to develop new drugs for NTDs, and he gives a great summary of the positive role of product development partnerships (PDPs).These chapters act as a powerful weapon in the battle against the NTDs.
Hotez begins each chapter with a couple of inspirational quotes, and I shall end with one of my favourites from the book – from Albert Sabin himself: “A scientist who is also a human being cannot rest while knowledge which might reduce suffering rests on the shelf.” And this book should rest on the bedside table.
I, Science (The Science Magazine of Imperial College)
Reviewer: Timothy Peplow
Review Date: July 28, 2014
Quarterly Review of Biology
24 November 2014
In this volume, the author tells the largely untold story of the world’s “bottom billion”—the poorest of the Earth’s inhabitants. His pithy yet impactful account represents a wealth of knowledge and wisdom for all audiences. Beginning with a crash course in all things “NTD” (neglected tropical dis-ease), Hotez gives his readers a sobering introduction to the scope and nature of NTDs. Elegantly contrasting the rapidly emerging, high mortality diseases that make headlines, the author highlights the longevity of the issue at hand—NTDs are ancient and chronic. Their high disease burden catalyzes poverty, conflict, and stigmatization, and their afflictions leave a path of socioeconomic, political, and developmental destruction in their wake.
After convincing his readers of their importance, Hotez carefully details what he deems the most devastating NTDs. Although his list of diseases is less than exhaustive and leaves out important players such as amebiasis, he provides readers with a balanced foundation in clinical manifestations, treatment/prevention strategies, socioeconomic and political consequences, current progress, and future directions. His rundown for each disease will satisfy both interested general readers and seasoned academics.
The true expertise of Hotez’s writing is most evident when he weaves together the subtle themes present in each of his chapters. In the final three chapters, he presents his passion tangibly—creating a collaborative framework for disease control. Again and again, Hotez recounts and encourages a movement to advocacy on a global scale. By detailing the coendemicity of NTDs (as well as other diseases such as HIV/AIDS, malaria, and tuberculosis), he makes a convincing case for the necessity of a robust and truly global commitment to NTD reduction and elimination.
Hotez enumerates each of the necessary collaborators in this commitment—the effort must be not only global, but also multifaceted. The author recognizes that realizing his vision will require the investment of governmental, academic, and industrial stakeholders. Importantly, this investment, Hotez highlights, does not hinge on altruism alone. Governmental investment provides novel avenues for international diplomacy and foreign relations. The involvement of industry provides “big pharma” with avenues to fulfill social responsibility as well as with public relations gold mines. Academia’s critical role catalyzes the continued development of a more international, more interdisciplinary, more fruitful status quo.
The honest genius of Hotez’s approach finds its home here and is exemplified by his concept of “antipoverty vaccines.” His realistic, balanced perspective is illustrated by call for administration of rapid impact packages of drugs and simultaneous execution of preparative measures for the possible emergence of drug resistance. The author’s balance of realism and idealism is his strength; he does not simply tally medical facts, public health statistics, or socioeconomic reports. Rather, his presentation truly interlaces every aspect of neglected tropical diseases—just as they are for the forgotten people of these forgotten diseases.
The Quarterly Review of Biology
Volume 89, Number 4
Reviewers: Caroline E. Stewart and William A. Petri
Review Date: December 2014
Midwest Book Review: Library Bookwatch (Online Book Reviews)
14 April 2014
Medical doctor and founding Dean of the national School of Tropical Medicine Peter J. Hotez presents Forgotten People, Forgotten Diseases, an in-depth discussion of neglected tropical diseases that among the most common infections of the world's poorest populations. Sicknesses covered include soil-transmitted helminth infections (such as hookworm infection), schistosomiasis (snail fever), tropical diseases that blind (such as river blindness and trachoma), mycobacterial infections, kinetoplastic infections (such as sleeping sickness and chagas disease), dengue, rabies, and much more. Now in an updated second edition, Forgotten People, Forgotten Diseases scrutinizes how these illnesses have harmed impoverished communities for centuries, and the economic and societal obstacles to treatment. The possibility of alliances between nongovernmental development organizations, as well as public-private partnerships, may allow a ray of hope to shine on a persistent, cyclical world health problem. A handful of color photographs, diagrams, and an index enhance this "must-have" for college and public library health and medicine collections, highly recommended.
Midwest Book Review
Library Bookwatch (Online Book Reviews) - The Health/Medicine Shelf
Reviewer: James A. Cox, Editor-in-Chief Midwest Book Review
Review Date: April 2014
Doody Enterprises
19 March 2014
Description
This book offers a summary of the neglected tropical diseases (NTDs), reviewing current international control efforts and describing what additional work needs to be undertaken to prevent the poverty-perpetuating effects of these diseases on the world's poorest people. The first edition was published in 2008.
Purpose
The purpose is to advocate for increased international efforts to control and eliminate NTDs. The review of the topic this book offers is invaluable. The goals of increasing awareness of NTDs, providing an understanding of the work done to date in the area, and describing the work that still needs to be done are effectively met.
Audience
The target audience is broad, including medical students and professionals, students of public health, policy makers and other individuals interested in helping the poor. Parts of the book unavoidably use scientific terminology, but not to the extent that prevents lay readers from understanding it. The author has a wealth of knowledge and experience on the topic.
Features
The book provides a summary description of the most common NTDs, such as intestinal worms, schistosomiasis, filariasis, trachoma, and onchocerciasis, illustrating their global importance because of their high prevalence the associated suffering and disability they cause. The book describes current international control efforts as well as work that needs to be done. The book makes an important but highly technical topic accessible to lay readers in a relatively brief book. Illustrations, tables, and end of chapter summary points help highlight the big picture amidst the details of the book.
Assessment
This is a worthwhile read for anyone interested in international health and the plight of the poor. It is a needed second edition, not because of changes in the diseases described, but because of the rapidly changing landscape of international organizations, collaborations, and control efforts that have blossomed over the last decade.
Doody Enterprises
Reviewer: Hans Dethlefs, MD (Heartland Community Health Network)
Review Date: September 2013
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