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73 6 Sub-­Saharan Africa Nigeria and South Africa The NTDs were conceived in the years following the launch of the Millennial Development Goals as part of a pro-­ poor strategy for Africa, with a focus on seven high-­ prevalence diseases that could be targeted with a “rapid impact” package of donated medicines [1]. Today, programs of mass drug administration are under way in more than 20 sub-­ Saharan African countries, led by USAID and British DFID NTD programs, with additional support from a private END Fund. In 2015, WHO determined that 35% of the eligible population in its African region is receiving access to essential NTD medicines [2]. In all, 229.5 million people in sub-­Saharan Africa received treatment in 2013 [2]. Over a similar time frame following the launch of the MDGs, the World Bank estimates that Africa’s economy has grown by an average of 4.4% annually [3]. This rate of growth in Africa has had a steep trajectory and may now even exceed Asia’seconomicgrowth,whichsomeexpertshavesuggested has been comparatively flat overall [4]. Based on the inverse association between national human development indices and worm indices noted previously , it would be useful to learn how much of Africa’s economic improvement might have resulted from the African component of the reductions in new HIV/AIDS, TB, and malaria cases, or the 25–39% decrease in global prevalence of some major NTDs such as LF, trachoma, onchocerciasis, and ascariasis —results that as I pointed out earlier were determined from the Global Disease Burden Study 2013. Since the launch of PEPFAR, PMI, GFATM, and the USAID and DFID NTD Programs, some countries in sub-­Saharan Africa have experienced impressive economic growth. Hotez.indb 73 6/22/16 11:02 AM 74 Blue Marble Health While Africa’s health and economic gains are impressive , their rise over the past decade continues to leave behind the massive yet forgotten bottom segment that remains mired in extreme poverty. The World Bank estimates that in 2011, 46.8% of sub-­ Saharan Africa’s population lived on less than $1.25 per day [5]. In some nations, such as Madagascar, almost 90% of the population lives below this World Bank poverty level [6]. The Potent Forces of Poverty and Conflict Sub-­ Saharan Africa’s conflict and postconflict countries, such as South Sudan and Central African Republic, are especially vulnerable to NTDs, as armed struggle is a potent force that depletes health systems already weakened from decades of profound poverty. As a result, the conflict and postconflict nations in Africa suffer from the world’s highest rates of NTDs [7]. In some areas of SouthSudan,trachoma,schistosomiasis,andLFareactuallyhyperendemic[7], meaning there is a constantly high prevalence or incidence of these NTDs. Other important examples of poverty and NTDs in postconflict Africa are offered by the three countries most affected by Ebola virus infection in 2014– 15: Guinea, Liberia, and Sierra Leone. These countries have emerged only relatively recently out of conflict and suffer from enormously high rates of extreme poverty and NTDs. While today Ebola virus infection is the best-­ known NTD linked to the conflicts in West Africa, it is also far less common than other diseases. Shown in table 6.1 is a 2015 analysis I published in PLOS NTDs indicating that while only about 0.1% of the population was infected with Ebola virus during the epidemic, approximately one-­ half of the people of Guinea, Liberia, and Sierra Leone suffer from schistosomiasis, hookworm infection, and malaria, as well as highly endemic dengue and onchocerciasis [8]. Together, these diseases combine to produce severe and long-­ lasting effects from anemia [9], including adverse pregnancy outcomes, reduced worker productivity, and impaired child development [10], such that the NTDs are major contributors to trapping generations of people in poverty. Despite sub-­Saharan Africa’s impressive economic gains, one-­half the region still lives with essentially no income. Conflict combines with poverty to promote NTD hyperendemicity. Hotez.indb 74 6/22/16 11:02 AM Sub-Saharan Africa 75 At the height of the Ebola virus crisis in the fall of 2014, I was interviewed almost daily on MSNBC, Fox News, or Bloomberg TV. While it was exciting to speak to large audiences about Ebola virus infection, for me it was also a source of frustration that many anchors and producers on those news shows did not care very much about West Africa’s high prevalence NTDs, such as schistosomiasis and hookworm infection, even though...


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