Gandhi’s Hookworms

Toward the end of his life, Mohandas Gandhi suffered from a hookworm infection. This disease, caused by blood-feeding worms in his intestine, is associated with severe anemia, lethargy, and fatigue. The fact that Gandhi’s vigorous efforts to wage peace in India may have been slowed because of hookworms is only one of the more dramatic examples of the deep connection between medical health and the promotion of international peace and security.

Today almost all of the 1.4 billion people who live below the World Bank’s poverty line are infected with hookworms or related parasites. Taken together, there are seven high-prevalence Neglected Tropical Diseases (NTDs) that particularly afflict low- and middle-income countries: six parasitic worm infections, which each afflict up to 1 billion people, and a bacterial infection known as blinding trachoma, which infects 60 to 80 million people.

In addition to their disproportionate impact on the poor, NTDs differ from the type of infections common in the developed world because, in the absence of treatment, they can persist for years or decades. NTDs produce chronic and disabling effects on child development and farm worker productivity, and they increase the risks of pregnancy. In doing so, these infections actually trap people in poverty — chronic hookworm infections in childhood reduce cognition, school performance, and future wage-earning potential by 40 percent or more.

India loses almost $1 billion annually in worker productivity because of elephantiasis, which is caused by filarial worms in the lymphatic system and genitals. Africa suffers similar economic losses from elephantiasis — as well as river blindness caused by larval worms in the eyes and skin, and schistosomiasis from worm eggs in the intestines, liver, bladder, or female genitals.

The people at highest risk for acquiring these NTDs also live in areas of greatest concern to the global security interests of the United States. As much as one half of the world’s poor who suffer from NTDs live in the nations that comprise the Organization of the Islamic Conference, including Yemen, Sudan, Somalia, and Afghanistan. Almost as many live in pockets of poverty in middle-income countries that either hold and maintain nuclear weapons stockpiles or aspire to produce them, including India, Pakistan, China, Iran, and North Korea. In these countries, people are not only trapped in poverty because of their health conditions, they are also trapped in conflict.

As NTDs spread throughout impoverished areas of Islamic countries and nuclear weapons states, they can promote global insecurity by increasing poverty and the possibility for radicalization. The security risks created by high endemic rates of NTDs argue strongly for seeking low-cost solutions for their control and elimination.

Fortunately, such measures are available and can be implemented for a tiny fraction of the cost of treating HIV/AIDS and other higher profile diseases. Several major pharmaceutical companies have agreed to provide many of the most important drugs used to combat NTDs free of charge, through well-orchestrated donation programs. Moreover, the drugs are effective even if they are given just once a year, making it possible to treat large populations in integrated, nationwide campaigns. Studies have demonstrated the feasibility and safety of simultaneously delivering three of the most commonly used drugs that target all six major worm infections at one time, while an antibacterial drug for trachoma can be administered at a later date.  In many cases, large-scale annual treatment campaigns can be conducted at a cost of $0.50 per person. There is also evidence that several rounds of annual treatments may actually eliminate some of these NTDs as a public health problem.

The initial funds for the first large-scale NTD control effort were provided under George W. Bush’s administration. These efforts are now being expanded by Barack Obama’s administration in order to treat tens of millions of people through annual mass drug administration at a cost of $65 million in 2010 — a sum that will possibly increase to $200 million in 2011.

Such funds represent less than 1 percent of White House’s annual global health budget, which is now focused heavily on HIV/AIDS treatment and prevention through the President’s Emergency Plan for AIDS Relief (PEPFAR). However, the health impact of NTD control is almost equivalent to that of HIV/AIDS, and, given the geography of where NTDs are most highly endemic, the modest costs required, and the potential for promoting global security, linking NTD control and elimination with U.S. foreign-policy goals makes a lot of sense. Because not all NTDs can be eliminated with existing drugs, there are further opportunities for joint research projects to develop new drugs, diagnostics, and vaccines between global health research scientists in the United States and in the nuclear weapons states where NTDs are endemic.

The low cost for NTD control and elimination efforts and the potentially high return in terms of global security suggest that such activities could eventually be integrated into the missions of the Department of State and the Department of Defense, especially as their policies relate to the OIC and nuclear weapons states. NTD "medical diplomacy" presents an opportunity of enhancing the technical expertise of American embassies abroad to provide support for national health ministries in the most affected areas, providing debt relief in exchange for attaining high drug treatment coverage, or encouraging ceasefires in areas of conflict in order to deliver essential NTD drugs. As we move into the 2010s, the medical community and the diplomatic corps must work together to translate global public health victories in NTD control and elimination into diplomatic rapprochement with the countries that make up the Muslim world and nuclear weapons states. Success in this important cause, it is fair to say, would be an achievement worthy of Gandhi.