The Blue Marble Health Collection: Redrawing Boundaries that Disease has Already Crossed

Peter J. Hotez, Co-Editor-in-Chief of PLOS Neglected Tropical Diseases, and Larry Peiperl, Chief Editor of PLOS Medicine, on a new PLOS Collection that highlights a shift in current thinking about global health.

This week PLOS Neglected Tropical Diseases and PLOS Medicine have joined forces to launch Blue Marble Health: the mismatch between national wealth and population health, the most recent PLOS Collection.

Two key PLOS papers, each published in the fall of 2013, stimulated the genesis of this Blue Marble Health Collection.

The poor living among the wealthy.

Major areas of poverty in the G20 nations and Nigeria, where most of the world’s NTDs occur.

The first, from PLOS NTDs – “NTDs V.2.0: ‘Blue Marble Health’—Neglected Tropical Disease Control and Elimination in a Shifting Health Policy Landscape” –  found that while some NTDs such as river blindness, loiasis, African sleeping sickness and schistosomiasis are largely or exclusively diseases of sub-Saharan Africa, paradoxically many of the world’s highest concentration of NTDs occur in the 20 wealthiest economies – the group of 20 (G20) countries – especially in the mostly hidden pockets of extreme poverty that can be found in the big middle-income nations, such as Indonesia or in areas of the  BRICS countries, including northeastern Brazil, northern India, and southwestern China.  Moreover, the disease burden from NTDs is alarmingly high in the southern United States, especially in Texas and the Gulf Coast, in areas of Australia with large Aboriginal populations such as the Northern Territories, and Eastern Europe.

A parallel editorial in PLOS Medicine – Poor Health in Rich Countries: A Role for Open Access Journals – noted that relative poverty within a society is a stronger predictor of health than aggregate measures of economic power such as GNP or per-capita income. For example, tens of millions of Americans living in poverty, including many people of color, “experience levels of health that are typical of middle-income or low-income countries.” The editorial concluded that, for many issues that affect the health of people of lower socioeconomic status, clear-cut distinctions between “domestic” and “cross-border” research are becoming increasingly difficult to draw.

Thus the conceptual framework of Blue Marble Health highlights a shift in current thinking about global health.  Increasingly an approach that highlights stark contrasts between developing and developed countries may no longer ring true.  Instead major health disparities including NTDs, but possibly also other infections such as tuberculosis as well as non-communicable diseases (NCDs) disproportionately affect the poor living among the wealthy.  Having evolved from paradigms of International Health (in high-income countries assist lower-income countries) through Global Health (in which countries work together to address health issues that affect the global community), Blue Marble Health advances the understanding that wherever socioeconomic inequality is pervasive, neglected diseases and other conditions naively assumed to arise only in the context of national poverty will spread.  To address these problems, Blue Marble Health calls for attention to socioeconomic, as well as biomedical factors – whether in Nigeria, South Africa, Brazil and India, or in the US, Europe and Australia.

Blue Marble Health

Blue Marble Health

The current collection is comprised of more than 20 Editorials, Viewpoints, Policy Forums, and Research Articles from PLOS NTDs and PLOS Medicine, as well as an Essay from PLOS Biology.  Each highlights a health disparity that disproportionately strikes the poor living in G20 countries or other countries generally thought of as well off.  The collection also coincides with the publication of a new PLOS NTDs editorial that identifies ten global “hotspots” for endemic and epidemic NTDs.

Mahatma Gandhi once stated: “It is a trite saying that one half of the world knows not how the other lives.  Who can say what sores might be healed, what hurts solved, were the doings of each half of the world’s inhabitants understood and appreciated by the other?”  (Indian Opinion, June 2, 1906. Found in Fischer L (Ed) The Essential Gandhi, Vintage Books 1962;  pp.325-6)  A century later, although the importance of appreciation among its diverse populations has only increased,  the world no longer divides itself  easily into halves on the basis of national boundaries or economic cut-points.  In the United Nations Human Development Report 2013 Nobel laureate in economics Amartya Sen articulates a distinction between “the difficult problem of assessing the richness of human lives, including the freedoms that human beings have reason to value, and… the much easier exercise of keeping track of incomes and other external resources that persons—or nations—happen to have.” In Sen’s words, “human well-being and freedom, and their connection with fairness and justice in the world, cannot be reduced simply to the measurement of GDP and its growth rate, as many people are tempted to do.”  Blue Marble Health recognizes that, as a fundamental prerequisite for well-being and richness in human lives, health must not be limited by simplistically defined boundaries, be they geographical or economic.

Moving forward we encourage the community of biomedical and social scientists, humanists, health economists, healthcare professionals, and public health workers to submit papers to us at PLOS that highlight health disparities among the poor and otherwise disadvantaged populations, those who are often forgotten in the world’s middle- and high-income countries.

Peter J Hotez MD PhD is Co-Editor-in-Chief of PLOS Neglected Tropical Diseases and Larry Peiperl MD is Chief Editor of PLOS Medicine.  Dr. Hotez is also Professor of Pediatrics and Dean of the National School of Tropical Medicine at Baylor College of Medicine, Texas Children’s Hospital Endowed Chair of Tropical Pediatrics, and President of the Sabin Vaccine Institute.  Dr. Peiperl is also Clinical Professor of Medicine at UCSF and an Attending Physician at San Francisco General Hospital.

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