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122 10 United States of America The finding of widespread NTDs among the poor in the United States was driven home almost literally as I took time to drive around some of the most impoverished areas of Texas, including Houston’s Fifth Ward. But even prior to my relocating to the Texas Medical Center in 2011, it was clear that NTDs have an intimate connection to poverty, including a significant but largely hidden level of poverty in the United States. In a 2006 paper published in the journal, Vaccine [1], and a subsequent article in the Lancet [2], we began to identify how NTDs not only occurred in the setting of poverty, but also were a major cause of poverty among the bottom billion. Notable among those effects were how NTDs reinforced poverty because of their long-­ term and deleterious effects on child development, intelligence, and cognition; the worker productivity of adults; and the health of girls and women, especially in pregnancy [1, 2]. NTDs and poverty were linked at the hip. It became increasingly clear that if you wanted to find NTDs, all you needed to do was to look for extreme poverty—and there they were. The Other America It was then I remembered a book I had read decades ago either in junior high school or high school titled The Other America: Poverty in the United States written by the social activist Michael Harrington, who in 1962 highNTDs can be found wherever you encounter extreme poverty. Hotez.indb 122 6/22/16 11:03 AM United States of America 123 lighted the hidden burden of poverty in an otherwise prosperous post– World War II America [3]. He ventured into America’s inner cities, the MississippiDelta ,Appalachia,andruralCalifornia,wheremigrantfarmworkers toiled, to eloquently describe millions of lives seldom viewed from our major highways and roads. His book was instrumental in convincing President Lyndon B. Johnson and his administration to launch the war on poverty , inaugurated with the president’s landmark State of the Union address in 1964. Years later, when I was a full professor, I found a torn and yellowed paperback copy of Harrington’s book. His opening paragraphs in the introductory chapter, titled “The Invisible America,” had a powerful effect: There is a familiar America. It is celebrated in speeches and advertised on television and in the magazines. It has the highest mass standard of living the world has ever known. . . . While this discussion was carried on, there existed another America. In it dwelt somewhere between 40,000,000 and 50,000,000 citizens of the land. They were poor. They still are. To be sure, the other America is not impoverished in the same sense as those poor nations where millions cling to hunger as a defense against starvation. This country has escaped such extremes. That does not change the fact that tens of millions of Americans are, at this very moment, maimed in body and spirit, existing at levels beneath those necessary for human decency . If these people are not starving, they are hungry, and sometimes fat with hunger, for that is what cheap foods do. They are without adequate housing and education and medical care [3]. Harrington’s words and message inspired me to begin a profound examination of poverty in the United States. According to the US Census Bureau, as of 2013, approximately 45.3 million people lived at or below the poverty line [4], roughly the same number as in Harrington’s Other America. However, back in 1962 that number was equivalent to almost one-­ quarter of the US population, whereas today it represents 14.5%. The poverty threshold set by the US government is a dollar amount for total yearly income for a family of four—currently between The new face of poverty in America: Today, 20 million Americans live in extreme poverty, and 1.65 million families in the United States live on less than $2 per day. Hotez.indb 123 6/22/16 11:03 AM 124 Blue Marble Health $20,000 and $30,000, which is based on a complicated array of parameters adjusted for inflation and other factors. I concede that most of the 45.3 million Americans living below the poverty line do not face the same desperate circumstances as the poorest people living in, say, China or Indonesia who live on less than $2 per day. Instead, with respect to America’s NTDs, I am concerned about the following two statistics: The first is from...


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