Intersectoral Approaches to Neglected Diseases

STEVEN K. AULT
Communicable Diseases Unit, Area of Health Surveillance and Disease Management,
Pan American Health Organization/World Health Organization,
Washington, DC, USA

The neglected diseases are a diverse group of communicable diseases that affect principally the
world’s poorest people. They are linked to poverty, as both a cause and a consequence of same, and
affect community security and family productivity. The neglected diseases cause acute and chronic
illness, disability, and sometimes death, and they may carry stigma for those infected. Current
interventions for neglected diseases emphasize the health sector, but to achieve sustainability
and simultaneously combat poverty, an intersectoral approach to their prevention and control is
needed. This chapter outlines some concepts for an intersectoral approach, including interventions
from the nutrition and food security, education, and environmental sectors.

Key words: neglected diseases; poverty; neglected tropical diseases; intersectorial; intersectoral;
Millennium Development Goals; Latin America and Caribbean; slum; rural; indigenous

The neglected diseases (NDs), sometimes referred to
as neglected tropical diseases, are a group of infec-
tious diseases found principally in poor or marginal-
ized communities (e.g., the rural poor, the urban poor
and slum dwellers, indigenous groups) in the tropics,
subtropics, and in parts of North America1 and other
temperate zones both historically and contemporar-
ily (whether imported or autochthonous cases). Glob-
ally, they affect more than 1 billion people and put
at least 2 billion at risk, or nearly one in three per-
sons on the planet. The World Health Organization
(WHO) has identified a group of 13 of these NDs that
are among the most common infections in many of
the poorest communities globally.2 They include par-
asitic and bacterial diseases or conditions that disable
or debilitate, such as lymphatic filariasis, leprosy, leish-
maniasis, and schistosomiasis; those that cause anemia
and adversely affect physical growth and development,
such as soil-transmitted helminthiasis (STH; ascaria-
sis, trichuriasis, and hookworm infection); those that
can cause blindness, such as onchocerciasis and tra-
choma; and parasitic zoonoses often transmitted as
part of the human food consumption chain.3 Other
important NDs in some poor communities include
dengue, skin diseases or conditions caused by bacteria
(e.g., Buruli ulcer, yaws), superficial fungi, ectopara-
sites (scabies mites; “sand fleas” causing tungiasis), and
myiasis-causing flies. Some NDs, such as schistosomi-
Address for correspondence: Steven K. Ault, 525 23rd St., NW,
Washington DC 20037. Voice: 202-974-3896; fax: 202-974-3331.
aultstev@paho.org
Ann. N.Y. Acad. Sci. 1136: 64–69 (2008). 
C 2008 New York Academy of Sciences.
doi: 10.1196/annals.1425.033 64
asis, visceral leishmaniasis, human African trypanoso-
miasis (HAT), and Chagas, disease, may also cause
death.
Neglected Diseases Linked to Poverty,
Governance, and Security
The NDs as a group contribute, directly or indi-
rectly, to global poverty and insecurity. In poor tropical
countries, where they are principally found, they con-
tribute indirectly to poverty and to social and physical
insecurity, which is the root of much social discontent
and civil unrest. They also contribute directly to eco-
nomic insecurity (victims unable to work or work full-
time), food insecurity (individuals disabled or chroni-
cally ill, preventing the generation of sufficient family
income), and social ostracization (the stigma of leprosy,
filarial lymphoedema, and hydrocele).4
The NDs are both a cause and a consequence of
poverty, and they are exemplified by STH, intestinal
infections that commonly infect from 25% to 100% of
poor communities—particularly the more vulnerable
members, such as children and pregnant women.
Hotez,5 in another chapter of this special issue, de-
scribes the connections between one STH, the hook-
worm infections, and poverty.
These diseases are characterized in part by lit-
tle public investment in surveillance, treatment, and
prevention. The NDs represent a governance chal-
lenge when and where government health services
do not reach the poor and marginalized, and they
contribute to disenfranchisement and even resentment
Ault: Intersectoral Approaches to Neglected Diseases
when treatment is not available; this is ironic in that
basic treatment for several NDs, such as preventive
chemotherapy for STHs, is neither expensive nor com-
plicated and treatment is cost-effective. Indeed, the
principal medicines to treat NDs are often donated by
pharmaceutical companies and foundations through
global alliances and by the WHO to countries (e.g., for
leprosy, lymphatic filariasis, onchocerciasis, trachoma,
and in some countries schistosomiasis). These public–
private partnerships (PPPs) are keys to the sustainable
control and, sometimes, elimination of certain NDs as
public health problems by simply improving access of
the poorest to needed medicines. Other PPPs are pur-
suing product development research into new drugs
and vaccines to treat or prevent NDs.
The STHs contribute to poor school attendance and
test performance, thus limiting the chances of success-
ful completion of schooling and the chance for better
employment. Intestinal helminthiasis and schistosomi-
asis contribute significantly to anemia in children and
young adults, limiting the ability of the latter to do
physical labor and thus reducing their income poten-
tial, especially in agrarian and rural societies. The NDs
contribute directly to economic insecurity in creating
limited access to schooling as a result of stigma (lep-
rosy, leishmaniasis, anthrax). The stigma surrounding
leprosy and lymphatic filariasis contributes to the lack
of interest of some health officials who themselves do
not well understand this group of diseases, and as a re-
sult entire families or communities can be ostracized or
estranged from access to both health services and em-
ployment. Finally, some NDs, such as the STHs and
tapeworms, contribute directly to food insecurity by
causing iron-deficiency anemia (especially where there
is coinfection with malaria) or by direct consumption
of micronutrients and calories that the infected host
(be they child, adolescent, mother, or worker) would
otherwise benefit from.
Current Interventions for Control
of Neglected Diseases
Several of the NDs have been the subject of verti-
cal control programs since at least the 1950s through
the 1980s (e.g., the vectorborne NDs, such as malaria
and onchocerciasis in tropical West Africa, which re-
lied principally on insecticide application). Today vec-
torborne ND control managers are expected to ben-
efit from a new emphasis on integrated vector man-
agement built on three decades of field research and
operational experience. New medicines and long-
lasting insecticide–treated bed nets for malaria and
new delivery systems, such as community-directed
65
treatment for onchocerciasis, have greatly changed
the choice of interventions. Leprosy, or Hansen dis-
ease, had historically been managed through leprosaria
with patient isolation and warehousing compounded
by stigmatism and sometimes abuse. Only in about last
two decades has leprosy treatment emerged from this
historic model to one of a more integrated and patient-
focused approach involving treatment, prevention of
disabilities, and rehabilitation conducted in public
health clinics or home and community settings—the
result of epidemiological research yielding improved
understanding of the risks of transmission, the advent
of new and effective multidrug therapy, and, more re-
cently, the work of social scientists and patient advo-
cates to combat social stigma and promote prevention
and rehabilitation.
In this decade several researchers, national public
health managers, WHO staff, pharmaceutical compa-
nies, and other partners in the Global Network for Ne-
glected Tropical Diseases have contributed to the pub-
lished WHO guidelines for preventive chemotherapy
for human helminthiasis.6 Hotez et al. have described
the current set of primary interventions and weaknesses
of the current approaches for control of the most preva-
lent NDs.2 The interventions are primarily preventive
chemotherapy (safe drug-based, single-dose medicines)
for the STHs, lymphatic filariasis, schistosomiasis, and
onchocerciasis, which are often donated to the poor-
est countries. Other NDs are currently treated with
drug combinations (leprosy, HAT), surgical care and
antibiotic applications (trachoma, Buruli ulcer), and
other interventions ranging from case detection
and management (HAT) to vector control (Chagas,
disease) and provision of safe water and water filters
(dracunculiasis).2 Preventive chemotherapy with the
single-dose drugs albendazole, praziquantel, and iver-
mectin was used to simultaneously treat populations
coinfected with STH, schistosomiasis, and lymphatic
filariasis, and this drug combination was safe and fea-
sible in children and adults in Zanzibar7 ; it represents
an integrated approach to preventive chemotherapy.
Most of the current interventions described earlier,
including integrated preventive chemotherapy, such
as applied in Zanzibar, are usually conducted by the
health sector and are considered health sector interven-
tions led by ministries of health (sometimes with sup-
port from nongovernmental organizations and other
partners). However, even if the evidence base is strong,
where ministries of health have a shortage of human
resources, a lack of information, and weak or ab-
sent geographic coverage in the poorest communities
(often the case), the sustainability of health-sector in-
terventions for the long-term sustainable control of
66
NDs alone appears not to be clear at this point. This
situation suggests that these new interventions, whether
integrated or not, will need to be accompanied by
medium- and long-term operational research to deter-
mine their sustainability.
Prevention and Control of Neglected
Diseases: A Multisectoral Problem
The application of epidemiological and operational
research to the prevention and control of the NDs over
the decades has resulted in a scientific literature that
is fairly rich in the identification of risk factors and
protective factors for several, but not all, NDs. Recent
improvements in the tools and applications of meta-
analysis of risk factors have further strengthened the
potential to extract clear lessons learned from such
research, though these have yet to be widely applied
to the NDs; some examples include meta-analysis of
the relationships between epilepsy and onchocerciasis8
and risk factors for subtle schistosomiasis morbidity9
and relationships between water resource projects and
schistosomiasis risk.10
Ehrenberg and Ault11 have summarized the mul-
tifactorial determinants of disease, including intrinsic
determinants, such as genetic makeup, and immune
response to extrinsic determinants, such as poverty, hu-
man activities in the environment, and vector ecology
and behavior. The extrinsic and intrinsic determinants
of communicable diseases, including the NDs, will of-
ten synergize negatively when clustered together. Poor
populations, such as many rural indigenous commu-
nities, migratory farm workers, and slum-dwellers, of-
ten suffer from deficient diets, which lead to immune
deficiencies and micronutrient deficits. These in turn
reduce their resistance to infection or coinfection with
parasites and ectoparasites. Poor families and com-
munities are often also forced to live in degraded or
high-risk natural environments, increasing risk of con-
tact with disease vectors and pathogens, such as Buruli
ulcer. Their status is also usually accompanied by poor
housing, water supply, and sanitation, which further
compound the risks of outbreaks or heavy burdens of
NDs. Where poor environmental conditions combine
with high population densities in poor communities
and households (whether in rural villages or slums), it
is common to observe clustering of NDs and coinfec-
tions in individuals.12,13
The situation may be further exacerbated in such
poor households and communities by coinfections
with other important communicable diseases, such as
malaria (e.g., anemia from malaria–STH coinfection)
Annals of the New York Academy of Sciences
and human immunodefieicncy virus (HIV). Strikingly,
Stillwaggon14 reviews some evidence that individuals
infected with schistosomiasis are more susceptible to
HIV infection and that individuals who receive a com-
bination of deworming (for STHs) and vitamin supple-
ments may reduce HIV transmission in poor African
communities. Helminth infections as a cofactor driving
HIV epidemics are further discussed by Hotez et al.15
As Stillwaggon14 notes, the environment of poverty
is complex, and the NDs form an integral part of this
web. As described earlier, risk factors and protective
factors for several NDs have been identified in sectors
or areas other than health. Some specific examples
include improved housing for controlling certain Cha-
gas, disease vectors; improved water supply and cloth
filters for dracunculiasis elimination; improved water
supply and sanitation combined with health educa-
tion for STH, filariasis, and trachoma prevention and
control; vegetation and peridomicile management for
leishmaniasis and Chagas, disease vector control; and
limiting human contact with forest or riverine environ-
ments to prevent transmission of HAT, onchocerciasis,
and leishmaniasis. Also, there are even more creative
ways to combat NDs by addressing some of the root
causes of the burden of NDs, as described next.
Intersectoral Action to Combat
Neglected Diseases and Poverty
What are some of the microlevel actions and exam-
ples of successfully combating both NDs and poverty in
developing economies and poor communities by work-
ing with other sectors? Three principal avenues can be
identified. The first avenue is through nutritional and
food security interventions to reduce anemia and un-
dernutrition. In poor communities it is common for
children to suffer from anemia and undernutrition be-
cause of a combination of STH infections and family
food deprivation. The important nature of comple-
mentary nutritional interventions (micronutrient pro-
vision, particularly vitamin A and iron, supplemen-
tal feeding) accompanied by deworming is recognized
by nutritionists, community health specialists, non-
governmental development organizations (NDGOs),
and United Nations agencies, such as UNICEF and the
World Food Program, which implement community-
wide interventions to combat child and maternal mal-
nutrition. These agencies have practices and policies
in certain settings that extend beyond deworming, mi-
cronutrient provision, and supplemental feeding to ad-
dress some of the causes of rural malnutrition. They
provide training in home and community gardening
Ault: Intersectoral Approaches to Neglected Diseases
and improved subsistence farming and forestry prac-
tices, small-scale livestock production, and microcredit
access to women to promote the establishment of fam-
ily gardens and orchards and other rural subsistence
businesses.
Some NDGOs, such as the World Wildlife Fund,
and bilateral agencies, such as DFID, GTZ, and US-
AID, have actively promoted agroforestry as a posi-
tive contributing factor to community health through
its direct effects of provision of tree fruits and nuts
to malnourished families and indirect effects on im-
proving income to purchase foods and medicines or
travel to health clinics for care. Other NDGOs, such as
Heifer International, seek the same objective through
the provision of small animals (poultry, ducks, rabbits,
and guinea pigs), small livestock (goats), fish, or hon-
eybees to contribute to both family nutrition and in-
come generation. As a whole, these interventions can
increase family food security and improve nutritional
status.
The second avenue is through education and school
health. The FRESH initiative (Focusing Resources
on Effective School Health) led by the World Bank
with WHO and other partners is a model that inte-
grates four key components: health-related school poli-
cies; provision of safe water and sanitation; skill-based
health education; and school-based health and nutri-
tion services, including deworming and micronutrient
supplementation. Deworming alone can increase rural
elementary school attendance by up to 25% in STH-
endemic areas in Tanzania16 ; the other components
of the FRESH program only further strengthen that
intervention. Interventions, such as mass deworming
of schoolchildren, which increase the opportunities for
children, particularly girls, to complete primary and
secondary schools, strengthen family economies and
address the severe economic gender-based gap seen in
many developing economies. Indeed, mass deworm-
ing of schoolchildren has been named a “best buy” for
both education and health by the MIT Poverty Action
Lab.17
The third avenue is through environmental inter-
ventions. The Pan American Health Organization
(PAHO)/WHO and UNICEF work with Primary En-
vironmental Care, an integrated and participatory ap-
proach to solving community environmental problems
on the basis of community diagnosis, dialogue with ex-
perts, advocacy, and municipal and stakeholder partic-
ipation. Water and sanitation–related NDs have been
targeted for priority community actions in Guatemala
and elsewhere using this strategy. The Biodiversity
Support Program coordinated by the World Wildlife
Fund18 has implemented several wildlife and habitat
67
conservation projects, principally in indigenous com-
munities that have environmental health components
to address diarrhea, dysentery, and inadequate drink-
ing water and sanitation. Other health interventions
by the World Wildlife Fund/Biodiversity Support Pro-
gram in Latin America and Africa included mobile
health team visits, primary health care postconstruc-
tion, family planning services, sustainable medicinal
plant and wild plant harvests to help residents remain
healthier and better nourished, and more effective par-
ticipation in local World Wildlife Fund conservation
programs. USAID’s Environmental Health Project im-
plemented an Integrated Population Health and Envi-
ronment Program in Madagascar that included a large
series of environmental and health interventions that
reduced the prevalence of several diseases in the target
communities19 ; the interventions included reforesta-
tion, forage crops, beekeeping, off-season gardening,
fish culture, fruit trees, plant nurseries, microcredit for
income generation, antierosion measures, market gar-
dens, potable water, sanitation and hygiene, vaccina-
tions, diarrheal disease and malaria treatment, nutri-
tion interventions (vitamin A), animal husbandry, and
ecosystem protection.
One is not limited to these three interventions while
seeking to build intersectoral approaches to combat
NDs and address poverty. Ault20 noted that a practical
package of intersectoral approaches may include the
following:
• Establishing intersectoral technical committees
and networks of stakeholders
• Improving water supply and sanitation in high-
risk communities
• Strengthening links between the communicable
diseases and the agricultural and livestock sectors
• Advocacy and communication with at-risk com-
munities and key external stakeholders about the
environmental and social determinants of health,
security, and poverty
• Community mobilization and participation
• Partnerships
• Environmental education
• Community economic development
Ehrenberg and Ault11 note that intersectoral inter-
ventions are expected to be cost-effective, by piggy-
backing or articulating ND control interventions with
other interventions that can reduce poverty, increase
family health and economic security, and promote sus-
tainability. Where costs of ND control are shared be-
tween the health sector and other sectors, or where
actions by other sectors reduce the prevalence, mor-
bidity, or distribution of NDs, it may be considered a
68
cost-effective action from the perspective of the health
sector’s financial director.
PAHO’s communicable diseases unit in collabora-
tion with veterinary public health unit has developed
an integrated and intersectoral project proposal for
the Chaco region, a harsh and impoverished area in-
habited principally by agrarian indigenous commu-
nities, in the border areas of Paraguay, Bolivia, and
Argentina. In the Chaco, the NDs include the STHs,
cutaneous leishmaniasis, Chagas, disease, and skin dis-
eases. Malnutrition is widespread. The Chaco project
is multidisciplinary and focuses on ND prevention
and control through primary health care, poverty al-
leviation through improved livestock production and
subsistence food production, and environmental man-
agement and protection. It reflects several initiatives
outlined by Holveck et al.4 for Latin America and
the Caribbean, including a focus on health of in-
digenous peoples, healthy spaces, productive munic-
ipalities, community-driven development, and inter-
sectoral cooperation between agriculture and health;
the project also addresses the issue of public health
and human rights for these isolated disadvantaged
communities. Stakeholder meetings are expected to
begin in 2008, and the 5-year project will be evalu-
ated for its intersectoral effects, cost-effectiveness, and
sustainability.
The WHO’s new Global Plan to Combat Neglected
Tropical Diseases 2008–201521 recognizes the impor-
tance of intersectoral action to control and eliminate
NDs. An intersectoral approach to combating NDs
and poverty also supports all eight of the United
Nations Millennium Development Goals,11 including
those that target the eradication of hunger; promoting
primary education (by increasing school attendance);
empowerment of women; reducing child mortality;
improving maternal health; combating HIV, malaria,
and other diseases; and ensuring environmental sus-
tainability in areas, such as urban slums. The PPPs
created to tackle the NDs also contribute to the Mil-
lennium Development Goal of global partnerships for
development.
Acknowledgments
I thank Drs. J.P. Ehrenberg, M. Roses, P. Hotez,
and J. Utzinger, as well as various managers, tech-
nical staff, consultants and interns from PAHO and
WHO, whose ideas and our conversations have con-
tributed to the development of this theme and this
report.
Annals of the New York Academy of Sciences
Conflicts of Interest
The author is a staff member of PAHO/WHO and
declares no conflicts of interest; however, the contents
of this report are the sole responsibility of the author
and should not be construed as speaking for the poli-
cies of PAHO/WHO or their governing councils and
assemblies. This report is a contribution to the current
global dialogue on poverty alleviation and the Millen-
nium Development Goals.
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