An epidemic in America’s backyard

When we discuss neglected tropical diseases and, more generally, the global burden of infectious diseases, images of worlds beyond our national borders come to mind. We think of “poor” people, of places without the same systems for waste disposal and sanitation, of countries without the infrastructure and hospitals we have in the United States. We think these problems are far away — HIV, intestinal worms, Chagas, dengue, Chikungunya, Trichomonus vaginali, elephantiasis, Toxoplasma gondii, river blindness — these diseases are “not in our backyard.”

The reality is that neglected tropical diseases are somewhat misleading in their name: they spread beyond the tropics. Many are becoming more and more prevalent in the United States (particularly in the South), and many others have been prevalent for years without ever receiving  the attention and recognition that American society gives them abroad. A recent article published in New Scientist highlighted one of my former Rice University professors, Dr. Peter Hotez, and discussed a concern Hotez has been advocating for years: the need to treat America’s “hidden epidemic.”

Where do epidemics hide? In our backyards where millions of people are living below the poverty line. How do epidemics hide? The media has done a fantastic job of educating Americans about the plagues of exotic diseases that occur elsewhere on the planet. Most people have a nodding acquaintance with the terms ‘malaria,’ or ‘AIDS,’ but we think of them as “in Africa” or other continents overseas. We have failed in educating people on diseases like Chagas and dengue — diseases most of us have never heard of. What is worse is the emphasis placed on these diseases being diseases of the developing world, not our over-developed America. We are not made to realize that all of these diseases are less exotic than they sound. We had 1.1 million reported cases of HIV in the U.S. in 2010. According to a New York Times article, last year there were 2.8 million cases of toxociarisis (a parasitic infection linked to neurological and respiratory problems) and 300,000 cases of Chagas disease (a parasitic infection spread by “kissing bugs” primarily in places with inadequate housing where the cockroach-like insects live in the walls). Programs like USAID, as valiant and beneficial as they are in the scope of our global community, are providing services elsewhere, not recognizing that we also need to provide these services at home. Because of the emphasis on parasitic diseases being foreign, many of our doctors do not recognize the diseases and consequentially, parasitic diseases are going untreated, undetected and spreading unrestrained.

Addressing the problem of neglected disease in America may not differ greatly from how it may need to be addressed abroad: by first addressing the issue of poverty. In the same 2012 NYT article, the number of children living in families earning less than $2 per person per day was 2.8 million in the United States. The article cited another 20 million people living in extreme poverty. That is here, in what has been called one of the wealthiest places on the planet.

Is this what poor looks like?

Is this what poor looks like? View from my window in Andasibe, Madagascar.

Reading American poverty statistics reminds me of the summer I spent in Madagascar. The first day I arrived, sitting in my host family’s living room, speaking in broken French, the first thing they asked me was to describe America. I showed them pictures of my family, our pet dog, the university I attended, the modest apartment I lived in. They were surprised that I didn’t live in a house like Hannah Montanna (the American T.V. show kids there enjoyed watching). They asked me if I was rich, and I said I was a student (in America that means no), and they said “There are no poor people in America.” Having seen poverty in America, I at first couldn’t believe that people elsewhere thought we somehow evade the universal problems related to unequal wealth distribution. Madagascar is consistently in the top 10 poorest countries in the world and on my first day there, I didn’t know how or whether it made sense to argue that America is poor too.

The Malagasy perception of America is not flawed, it is the image we put forth in this world. Our music, television and movies portray an America that is far removed from problems people face in American reality. The Americans who do make it to Madagascar have somehow afforded the expense of flight and travel that Malagasy people see as outlandish. On television, we have tremendous wealth captured by frivolous shows like Jersey Shore or New Girl. These shows set a false image of middle-class America by representing middle-class as something it is not. Marketplace Wealth & Poverty reported that the average house portrayed by Hollywood reflects a house for an American making $150,000 annually, compared to the more realistic middle-class income of $55,000. The article reports that only 15 percent of Americans could afford the types of living conditions portrayed as middle-class on television. The world thinks we have no poor people. And I was wondering why.

On our way to the community shaman's house, my "sister" points out goyave, used as an anti-diarrheal. Community and knowledge is shared.

On our way to the community shaman’s house, my “sister” points out goyave, used as an anti-diarrheal. A sense of community and a wealth of knowledge are shared. Can interdependency alleviate poverty?

For the past three years I have been thinking about what “poor” means. My time in Madagascar, where the average income is $948 annually according to TechScio’s data on wealth, changed my perception. During my rural home stay, my family had what people here term “poor” in the sense that we lacked the amenities American homes are accustomed to: we had no front door, no screens, no window panes, no running water; we had straw beds and a wooden outdoor outhouse and we took turns making breakfast at the neighbors house so the whole neighborhood wasn’t burning more firewood than was needed. We took bucket showers outside, where we had views of jungle with wild poinsettias and the famous rose periwinkle (a plant-based treatment for childhood leukemia, which grew weed-like in our backyard). We ate rice three times a day and rice-water in between. And at no point did we live like the image of poverty I had learned in America. In the U.S., we think of our “poor” as sleeping on park benches, standing in line at the shelter, begging on corners, we create a sense of pity because we see the stark contrast between white collared workers in the buildings that other people stand begging outside. By global standards, that summer I was living below the poverty line, but at no point did “poor” feel “poor.” People were happy. We played soccer and went to bed with the sun. The community shared resources and a sense of togetherness which eliminated the distinction between “have” and “have not.” A “poor” country seemed rich in many ways.

More recently I picked up one of Alexis de Tocqueville‘s lesser known works: Memoirs on Pauperism. De Tocqueville, writing ca. 1835, had insight into the causes and perpetuation of poverty that seems so relevant to our current world, I still find it frustrating that his work has not risen to more fame and has not had more influence on the subsequent development of aid programs and economic policy. De Tocqueville makes an observation of one of the first government “poor laws” which was instituted by the Justices of the Peace of Berkshire meeting at Spleenhamland in 1795. He notes that if one observes poverty levels before and after the institution of this government policy to assist the poor, poverty actually became worse following the law than prior to. He also writes in detail on other long term effects (decrease in productivity, lower wages, higher food prices, etc.) which he sees as being prompted by poor laws resulting in a sense of dependency on and even entitlement to government aid.  He describes a perpetuating cycle of poverty that worsens when people lose motivation. In de Tocqueville’s perspective, it seems that when there are multiple ways to solve a problem, the best way is through community collaboration —having a dependency on neighbors whom one feels responsible to “pay back”  and which is an unreliable form of consistent aid (only turned to in crisis). The government, because distanced from the community, fosters a sense of dependency which can lead to lower levels of motivation to resist government charity as opposed to charity from neighbors. Lack of motivation leads to the perpetuation of poverty that de Tocqueville observed in terms of lowered productivity which in turn leads to higher prices and lower wages.

If this is the case, and our efforts to end poverty may be better if prompted by community efforts rather than government, I think more of us need to volunteer. We need to help the people just outside our backyards. We can donate money to organizations overseas and watch on the news the exotic problems of developing nations, but that keeps us blinded from the problems here. We have a growing number of neglected infectious diseases which can be taken as a crude measurement for what I see as the largest neglected epidemic we have in this country: American poverty. What are we going to do about it?

*The photos used are from my personal collection, please do not use without permission.


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