BMC Public Health

BMC Public Health
BioMed Central
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Debate
Prevention, control, and elimination of neglected diseases in the

Americas: Pathways to integrated, inter-programmatic,
inter-sectoral action for health and development
John C Holveck1, John P Ehrenberg1, Steven K Ault*1, Rocio Rojas2,
Javier Vasquez3, Maria Teresa Cerqueira4, Josefa Ippolito-Shepherd5,
Miguel A Genovese6 and Mirta Roses Periago7
Address: 1Area of Health Surveillance and Disease Management, Pan American Health Organization/World Health Organization (PAHO/WHO),
525 23rd Street NW, Washington D.C. 20037, USA, 2Area of Technology and Health Services Delivery, Pan American Health Organization/World
Health Organization (PAHO/WHO), Av. Amazonas 2889 y Mariana de Jess, Quito, Ecuador, 3Area of Technology and Health Services Delivery/
Area of Legal Affairs, Pan American Health Organization/World Health Organization (PAHO/WHO), 525 23rd Street NW, Washington D.C.
20037, USA, 4Field Office, US-Mexico Border, Pan American Health Organization/World Health Organization (PAHO/WHO), El Paso, Texas
79912, USA, 5Area of Sustainable Development and Environmental Health, Pan American Health Organization/World Health Organization
(PAHO/WHO), 525 23rd Street NW, Washington D.C. 20037, USA, 6Veterinary Public Health, Pan American Foot and Mouth Disease Center
(PANAFTOSA), Avenida Presidente Kennedy 7778, Sao Bento, Duque de Caxias, 25040-004, Rio de Janeiro, Brasil and 7Pan American Health
Organization/World Health Organization (PAHO/WHO), 525 23rd Street NW, Washington D.C. 20037, USA
Email: John C Holveck - [email protected]; John P Ehrenberg - [email protected]; Steven K Ault* - [email protected];
Rocio Rojas - [email protected]; Javier Vasquez - [email protected]; Maria Teresa Cerqueira - [email protected]; Josefa IppolitoShepherd - [email protected]; Miguel A Genovese - [email protected]; Mirta Roses Periago - [email protected]
* Corresponding author
Published: 17 January 2007

BMC Public Health 2007, 7:6
doi:10.1186/1471-2458-7-6
Received: 31 March 2006

Accepted: 17 January 2007
This article is available from: http://www.biomedcentral.com/1471-2458/7/6

2007 Holveck et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Background: In the Latin America and Caribbean region over 210 million people live below the poverty line. These
impoverished and marginalized populations are heavily burdened with neglected communicable diseases. These diseases
continue to enact a toll, not only on families and communities, but on the economically constrained countries themselves.
Discussion: As national public health priorities, neglected communicable diseases typically maintain a low profile and
are often left out when public health agendas are formulated. While many of the neglected diseases do not directly cause
high rates of mortality, they contribute to an enormous rate of morbidity and a drastic reduction in income for the most
poverty-stricken families and communities. The persistence of this "vicious cycle" between poverty and poor health
demonstrates the importance of linking the activities of the health sector with those of other sectors such as education,
housing, water and sanitation, labor, public works, transportation, agriculture, industry, and economic development.
Summary: The purpose of this paper is three fold. First, it focuses on a need for integrated "pro-poor" approaches and
policies to be developed in order to more adequately address the multi-faceted nature of neglected diseases. This
represents a move away from traditional disease-centered approaches to a holistic approach that looks at the
overarching causes and mechanisms that influence the health and well being of communities. The second objective of the
paper outlines the need for a specific strategy for addressing these diseases and offers several programmatic entry points
in the context of broad public health measures involving multiple sectors. Finally, the paper presents several current Pan
American Health Organization and other institutional initiatives that already document the importance of integrated,
inter-programmatic, and inter-sectoral approaches. They provide the framework for a renewed effort toward the
efficient use of resources and the development of a comprehensive integrated solution to neglected communicable
diseases found in the context of poverty, and tailored to the needs of local communities.
Page 1 of 21
(page number not for citation purposes)
Background
Broader understanding of poverty
Extreme poverty coupled with environmental degradation
continues to undermine and circumvent progress toward
poverty reduction. The statistics have provided a sobering
reality in regards to the current state of affairs in many
parts of the world (see Table 1).
Development thinking and practice have evolved in ways

that should prove more conducive to tackling the multidimensional nature of poverty. Even the understanding of
poverty as a concept has broadened. As the Global Poverty
Report 2000 makes clear,
"Poverty goes beyond a lack of income. It is multi-dimensional, encompassing economic, social, and governance
perspectives. Economically, the poor are not only
deprived of income and resources, but of opportunities.
Markets and jobs are often difficult to access, because of
low capabilities and geographical and social exclusion.
Limited education affects their ability to get jobs and to
access information that could improve the quality of their
lives. Poor health, due to inadequate nutrition and health
services, further limits their prospects for work and from
realizing their mental and physical potential [9].
Poverty and conflict
Today, conflict affects some 35 of the world's poorest
countries. The uncertainty that comes as a result of living
amidst violence erodes social capital and destroys families, creating an environment that makes reintegrating
combatants and rebuilding cohesive political systems very
difficult [10]. Evidence from case studies and statistical
analyses suggests that rising levels of poverty, a decline in
state services, and sharp political, social and economic
horizontal inequalities between groups are major causes
of conflict [11,12]. Environmental degradation, population pressure, falling agricultural productivity and scarcity
of water, have also been linked to conflict, as they are
sources of poverty [13-15]. These unstable environments
are national security threats for both wealthy and poor
countries [16].
These threats will continue to rise as poverty is expected to

increasingly move from rural to urban areas [17]. The
worldwide urbanization of poverty accelerates the risk of
instability [18]. This fact becomes particularly noteworthy
as the rate of the urban population in developing countries is expected to double over the next 20 years.
The final straw: disease
The World Health Organization (WHO) estimates that
diseases associated with poverty are responsible for 45%
of the total disease burden in developing countries [19].
The Millennium Development Goals (MDGs), as well as
http://www.biomedcentral.com/1471-2458/7/6
several other global initiatives have focused exclusively on

the control of major communicable diseases with high
mortality rates, such as HIV/AIDS, tuberculosis, and
malaria. However, this focus has left out a considerable
list of "other diseases" that have been aptly coined the
"neglected diseases" (NDs). These diseases have been
given relatively little attention by national governments
and are considered to be low priority international public
health issues.
Neglected diseases
The NDs are largely comprised of infectious tropical diseases. Today, NDs can be usefully considered as a group
because they are concentrated almost exclusively among
impoverished populations living in marginalized areas.
These incapacitating diseases, such as lymphatic filariasis,
onchocerciasis, schistosomiasis, soil-transmitted helminthiasis (ascariasis, trichuriasis and hookworm infection),
Chagas disease, Buruli ulcer, leishmaniasis, leprosy, and
trachoma continue to inflict severe disability and sometimes death. Though the phrase "neglected tropical diseases" is commonly used in the literature today, we have
instead chosen the broader phrase "neglected diseases"
because some of the infectious diseases of concern in the
Americas, such as plague and leptospirosis, are not geographically limited to the tropics and sub-tropics. The
NDs also contribute to the overall burden of communicable diseases in the region
Although medically diverse, NDs share features that allow

them to persist in conditions of poverty where they frequently overlap [20]. These conditions of poverty include
unsafe water, poor sanitation and refuse disposal, which
sustain transmission cycles and favor the proliferation of
vectors that transmit disease. Other conditions, such as a
lack of access to health services, low levels of literacy,
inadequate nutrition and poor personal hygiene all help
to increase vulnerability to infection and work against prevention efforts. Specific technical opportunities to control
NDs in LAC through inter-sectoral and multi-disease
approaches were recently reviewed [21], and complement
this paper which focuses principally on inter-programmatic opportunities for synergy within health agencies
with a focus on PAHO.
Neglected populations
Neglected populations living in poverty throughout the
developing world (e.g., slum and shanty-town dwellers,
numerous indigenous groups and small ethnic groups,
and the rural poor including migratory workers in agriculture, miners, and fishers) are often heavily burdened by
communicable and non-communicable diseases, and
highly marginalized by the health sector. In some areas
women and children may be considered neglected populations due to their limited access to health and social sup-
Page 2 of 21
Table 1: Poverty statistics among the world's population of 6 billion
Almost 3 billion on less than $2 per day, and 1.2 billion people are estimated to still live on less than $1 per day [1]. In Latin America and the
Caribbean (LAC), which has a total population of 561 million [2], 132 million live on less than $2 a day, and 57 million live on less than $1 per day
[3]
2.4 billion people lack basic sanitation [1]
2 billion people are without electricity [4]
1 billion adults are illiterate [1]
1 billion people are without adequate shelter [4]
110 million school-age children are out of school, 60% of them girls [1]
1 billion people lack access to safe water [1]
880 million people lack access to basic health services [5]
790 million people lack adequate nutrition [1]
250 million children between the ages of 5 and 14 do wage work outside their household often under harsh conditions [6]
One third of human deaths, some 50,000 daily, are due to poverty-related causes and thus avoidable, insofar as poverty is avoidable [7, 8]
port services. This hinders their ability to exercise their

basic human rights and fundamental freedoms, especially
the right to physical and mental health
A reduction in the communicable disease burden would
enable these communities and groups to become more
economically active and therefore further reduce the socioeconomic factors contributing to disease. A reduction in
the total ND burden may not only improve the overall
economic performance of families and communities, but
of entire nations.
Millennium Development Goals
In 2000, all 191 United Nations member states unanimously pledged to meet eight MDGs by the year 2015.
Among this agenda are the explicit goals of eradicating
extreme poverty and hunger (MDG-1), and ensuring environmental sustainability (MDG-7). Communicable diseases are overarching issues of sustainable development
rather than exclusively health matters, as evidenced by the
high long-term costs, loss of productivity and social burdens associated with illness and disability from NDs,
which go beyond the usual economic analysis of ill
health.
Although NDs are not explicitly mentioned among the

MDGs, the goals cannot be fully achieved without an integrated strategy which includes their prevention, control or
elimination. An integrated strategy which includes the
NDs supports all eight of the MDGs including ten out of
the eighteen Millennium Declaration targets. Several
examples of how integrated ND control supports the
MDGs are listed below:
De-worming cost-effectively improves the nutritional status of poor children, contributing to the goal
of Eradication of Hunger (MDG-1) [22-25], and combines well with vitamin A supplementation.
De-worming improves school attendance and thus

increases the chances of completing primary education, contributing to the goal of Primary Education
(MDG-2) [22,23,26]
Promoting income-generating activities such as
micro-enterprises for poor women to produce insecticide-treated bed nets, combined with educating mothers in child care and health skills contributes to the
Empowerment of Women (MDG-3) [27].
Reducing the combined burden of multiple parasitic
diseases (poly-parasitism) [28] and micronutrient
deficiencies contributes to the Reduction of Child Mortality (MDG-4).
Controlling iron deficiency and anemia due to hookworm results in the Improvement of Maternal Health
(MDG-5) [29].
Combating NDs contributes to the goal of Combating
HIV, Malaria and other Diseases (MDG-6) [30] especially where co-infection compounds the health problems of AIDS and malaria victims.
Implementing environmental sanitation (safe
excreta and wastewater disposal) reduces fecal contamination of soil, water, and irrigated crops, contributing to Ensuring Environmental Sustainability (MDG7).
Inter-sectoral approaches to ND prevention and control involve establishing extended partnerships compatible with the goal of Global Partnerships for
Development (MDG-8) [31].
A bold ND prevention and control effort coordinated with
other sectors and activities, has the ability to drive the
agenda for sustainable development and help achieve the
Page 3 of 21
targets for the MDGs. Keeping this objective in mind this

paper seeks to examine the following questions:
How can an integrated ND agenda provide entry
points to unify and coordinate the various programs
and sectoral agencies involved?
What are the current PAHO and other institutional
initiatives that incorporate and highlight entry points
for inter-sectoral initiatives and integrative approaches
to health? Are there successful country examples of
these initiatives in action?
What are the common elements that provide a
framework for an integrated, inter-programmatic, and
inter-sectoral strategy for the prevention, control, and
elimination of NDs?
Discussion: the case for a different approach

Rationale for an integrated approach
NDs and the environment in which they flourish are intimately tied with other issues of sustainable development,
therefore allowing the ND agenda to provide an ideal
entry point to develop new paradigms of action. The
introduction of basic public health measures in communities would significantly reduce the burden of a number
of diseases where these elements play an important role.
There is also a considerable overlap in the prevention and
management of these diseases, permitting useful synergies
amongst these efforts. It is now an opportune time to link
an integrated ND strategy with the newly emerging global
partnerships addressing HIV/AIDS, tuberculosis and
malaria, in order to take advantage of the economies of
scale that occur during the scaling up process of these global initiatives [32].
There exists an urgent need to develop innovative tools to

combat NDs, particularly ones that move away from a vertical, single disease-centered approach to those that focus
on a more horizontal population health approach. The
population approach encompasses a broader notion of
health which recognizes the range of social, economic and
physical environmental determinants that contribute to
health. By providing opportunities for integrative solutions to health conditions, and by fostering participatory
approaches at the local level, these neglected populations
will be better equipped to identify determinants that contribute to poor health, thereby allowing them to exercise
their basic human rights, and ultimately break out of the
cycle of poverty and illness.
Integrated, inter-programmatic, and inter-sectoral
approaches
Integrated, inter-programmatic and inter-sectoral
approaches are not new phenomena. They represent a
working multi-disciplinary framework or strategy for

which countries, technical assistance organizations and
governments should work toward.
The word 'integrated' stresses that the object or system of
interest is a complex, multi-dimensional one, and consists
of different interacting elements. These interacting elements may be assessed by examining the available
resources within an equity framework. 'Inter-programmatic' approaches represent opportunities to combine two
or more disease-specific or health-specific programs,
which are often found in the same health agency.'Inter-sectoral' partnering is the process of creating joint interorganizational initiatives across two or more sectors
inter-sectoral partnerships involve collaboration between
organizations that may be based in various sectors: the
state (government), the market (business), and civil society (non-governmental organizations (NGOs), non-profits, etc.)" [17].
In the specific context of the ND agenda, integrated, interprogrammatic and inter-sectoral approaches to reach marginalized populations or geographic areas, based on stratification of risks, provide added value for several reasons:
They represent solutions by "piggy-backing" one disease control intervention with another. For example,
combined therapies may be used to control soil-transmitted helminths, schistosomiasis, and lymphatic
filariasis by jointly administering praziquantel and
albendazole in the same interval [33-35].
They provide added benefits to the community at
large by drawing attention to issues that generally fall
outside the purview of the health sector and are intrinsically related with States' human rights obligations
(e.g., improved housing and education, provision of
clean water, safe disposal of excrement).
They have the potential to greatly increase the standard of living for the local community by recognizing
the economic impact that these diseases have as a
result of disability and lost productivity.
Many complex issues, such as housing for the urban poor
and local economic development require a wide range of
resources and abilities that integration, inter-programmatic and inter-sectoral efforts are the only viable
approaches to effectively address them over the long-term
and help to reduce the duplication of activities. These
approaches can also stimulate innovative solutions by
addressing the diverse goals of various participants. In
effect, they can produce activities in which "the whole is
more than the sum of its parts" [36].
Page 4 of 21
The combination of these approaches are emerging as an

increasingly important development strategy. Current
trends in the LAC region include a decline in international
development funding, the slow decentralization or devolution of national government power and function to
municipal and local entities, heightened involvement of
the private sector in social issues, and an increasing
number of civil society actors [37]. This implies the need
for more effective coordination among government programs, increased transparency through participatory
approaches and increased access to better information for
all stakeholders.
Opportunities among existing initiatives
Technical cooperation of WHO/PAHO has evolved strategically in direct support to mid-level and local governments and agencies within the framework of
decentralization and local development. In particular,
there are eight initiatives which provide entry points and
opportunities for integration and inter-sectoral partnerships at the local level. They are discussed in more detail
below.
They include:
I. Health of the Indigenous Peoples of the Americas Program (PAHO/WHO)
I. Health of the Indigenous Peoples of the

Americas Program
The Health of the Indigenous Peoples of the Americas
(HIPA) Program represents a specific population characterized by precarious health and living conditions, due to
an elevated exposure to several factors including; the gradual destruction of the ecosystems supporting their communities, overexploitation of natural resources, natural
disasters and the local capacity to respond, labor migration patterns, alcohol abuse, and indiscriminate land colonization by other groups. All of these factors play a
significant role in the alarmingly high burden of disease
that is ever present within this population. Some communicable diseases that occur with great frequency within
this population include malaria, onchocerciasis, acute respiratory infections, tuberculosis and helminthiasis. Additionally, these populations are often plagued with
malnutrition, skin infections and diarrhea [38].
In light of the marginalized and underrepresented nature
of the indigenous peoples, several attempts have been
made to identify strategies that could provide formal
health care to this population through an integrated
approach while taking into consideration their distinct
historical and socio-cultural characteristics. The HIPA Program is a primary example of how integration, inter-programmatic and inter-sectoral activities can provide a
synergistic benefit to neglected populations.
II. Productive and Healthy Municipalities (PAHO/WHO)

III. Community Driven Development (World Bank)
IV. Healthy Municipalities and Communities Initiative
(PAHO/WHO)
V. Health-Promoting Schools Regional Initiative (PAHO/
WHO)
VI. Primary Environmental Care (PAHO/WHO)
VII. Inter-Sectoral Cooperation: Health and Agriculture
(PAHO/WHO)
VIII. Initiative on Public Health and Human Rights
(PAHO/WHO)
These initiatives provide a strong foundation to build
upon in the LAC region. By examining the overlapping
and complimentary features it may be possible to bolster
and scale up what has been proven to work, as well as foster future collaborative action.
The HIPA Program highlights the importance of four lines

of work; advocacy and the development of technical
capacity and coordination; policy development and targeting for the achievement of the MDGs; information and
knowledge management; and primary health care with an
intercultural approach.
The program articulates the ability and willingness to
incorporate inter-programmatic and inter-sectoral
approaches tailored to the needs of specific indigenous
populations. The HIPA Program notes that "The establishment of intra-institutional, inter-institutional, and intersectoral partnerships has facilitated the incorporation of
the health of the indigenous peoples of the Americas into
the political agendas and of work within the organization
and in institutions that have directives regarding the
indigenous peoples of the Region"[38]. Furthermore, the
initiative highlights several current integrative and interprogrammatic activities in 14 areas: integrated management of childhood illnesses (IMCI), malaria, tuberculosis,
reproductive health, water and sanitation, maternal and
child health, virtual campus, mental health, human
rights, sexually transmitted infections (STI)-HIV/AIDS,
social exclusion, health of older adults, oral health, eye
health and rehabilitation [38].
Page 5 of 21
By incorporating a ND component several areas may be

highlighted that affect the overall health of specific indigenous populations. As most of these diseases are associated with environmental and behavioral factors, the
following areas should be addressed: poor living conditions, unsafe drinking water, inadequate sanitation and
excreta disposal, poor drainage, inadequate solid waste
removal, poor housing, indoor air pollution and occupational exposure to natural and environmental hazards
(e.g, risk of lead and mercury intoxication).
Water and Parasitic Diseases among Indigenous
Populations
High prevalence rates of many parasitic diseases among
indigenous populations have been documented [39]. In
some indigenous communities, researchers have identified prevalence rates of intestinal helminths as high as
90% [40]. The diseases caused by a scarcity of clean water
are the principal causes of morbidity and mortality for
indigenous populations [38].
An investigation of the Pankararu indigenous tribe in the

state of Pernambuco, Brazil, identified multiple intestinal
parasites in nearly all members of the community.
Researchers tested relations between daily living conditions (housing, sanitation, water supply/treatment, and
garbage disposal) and the number of different parasite
species found in the same household. The study concluded that these living conditions had a profound impact
on the number of intestinal parasites found among the
Pankararu community, with particular emphasis on those
relating to lack of adequate water sources and water treatment [41].
Though natural resource development projects have
sometimes been linked to the spread or intensification of
some parasitic diseases, well-planned development
projects which involve local communities in planning
and implementation can prove beneficial [42]. For example, efforts in the Peten region and Mayan Biosphere
Reserve in Guatemala are a working example of an integrative approach to resource management and indigenous
population initiatives fostered by local community participation. In 1988, a strategy for sustainable development
for the Peten region was developed by the World Conservation Union (IUCN) at the request of the Guatemalan
government. In this particular region of Guatemala, recent
changes in land use for the implementation of agro-export
commodity schemes have resulted in major climatic and
environmental disturbances, changing ownership rights
and an overall decline in the quality of life of its indigenous inhabitants [38]. In response to the continual deforestation, inadequate sanitation infrastructure, and
diminishing water resources, the Secretary General of
Development and Planning (SEGEPLAN) with technical
support from a bi-lateral agency (USAID), developed a

plan to utilize local participation by resurrecting ancient
irrigation techniques for water supply and aquaculture.
The project gave primary attention to the incorporation of
ancestral technologies of Mayan origin through demonstrative activities that ensure local community participation concerning health, agriculture, and safe and adequate
water and sanitation provision [38].
Education and school health among indigenous
populations
Several studies have also examined disparities between
indigenous schoolchildren and urban schoolchildren. In
a study comparing rural Queimadas Indian schoolchildren with urban schoolchildren in southern Brazil, results
demonstrated a strong statistical correlation between
stunting and the intensity of soil-transmitted helminth
infections among the Queimadas schoolchildren [43]. In
a related study, these researchers found that housing/
hygiene indicators were significantly poorer for the indigenous schoolchildren, and that there existed a statistically
significant positive correlation between total prevalence
of soil-transmitted infections and prevalence of highintensity infections with most variables for poor housing
and hygiene. On the basis of these results, recommendations were given to administer mass anti-helminthic treatment in conjunction with educational interventions [44].
Objectives of the HIPA program
The HIPA Program has several reoccurring themes, such as
a call for inter-sectoral collaboration and a renewed effort
toward health promotion that "brings together efforts and
finds the synergy of actions underway in the countries in
achieving the MDGs and the renewal of the primary
health care strategy" [38].
The HIPA Program notes, "There is an urgent need for

identifying innovative, and at the same time respectful
and practical forms [of interaction] to work with the
indigenous representatives and to show concrete results
whose evidence can be reflected in the reduction of the
disease and death in the indigenous communities. This
implies the promotion of an integrated work plan that
takes into account the conceptions and institutional and
community frames of reference and integrates the policies, plans, and action programs considering the
strengths, wisdoms, authorities, demands, and processes
characteristic of the indigenous peoples within national
societies" [38].
These specific action programs in indigenous health represent significant opportunities to reduce the burden of
ND on specific neglected populations by considering the
comprehensive health determinants that affect indigenous people. This initiative also has the potential to be
Page 6 of 21
linked with existing networks of NGOs and other organizations focusing on indigenous populations, which
would result in improved environmental sanitation,
health education, integrated drug administration, and a
focus on nutrition in order to reduce the disproportionate
burden of NDs facing these populations.
II. Productive and Healthy Municipalities

Initiative
Poverty rates in rural areas are far higher than in the urban
areas, with 64% of the rural population living below the
poverty line [45]. The poverty line is calculated according
to a 'basic basket' of goods and services that take into
account prevailing wage and price structures [45]. Rural
poverty disproportionately afflicts women, children and
the elderly [46]. Social and economic indicators in rural
areas are worse when compared with urban areas. The
majority of the indigenous peoples (approximately 80%
of 34 million people) located in rural Mexico, Peru,
Colombia, Bolivia, Ecuador, and Guatemala are poor
[47]. These facts exemplify a close relationship between
rural poverty and ethnicity.
Rural development has traditionally been exclusively
associated with agriculture. Putting too much emphasis
on agriculture and ignoring other aspects of rurality is a
pitfall that has been repeated for decades. The policy shift
towards integrated rural development reflects the recognition of complex interactions within the system of overall
rural development. Integrated rural development provides an alternative to agriculture alone as a source of
income and livelihood. This shift represents a fundamental change in policy objectives toward a more holistic and
sustainable approach to rurality amongst the most marginalized rural populations [48].
Rural populations face a high-level of social exclusion and
social inequity. Many livestock and agriculture products
are generated by impoverished and disease-prone workers
living in unhealthy environments. With these considerations in mind, PAHO's Productive and Healthy Municipalities (PHM) Initiative articulates an approach to
combining agriculture and health in the context of local
development to be implemented in rural areas of small
livestock producers. This allows for a greater potential to
reduce poverty through the improvement of livestock production of small producers [49] combined with rural primary health care.
The PHM Initiative has strong implications for NDs
amongst agriculture and livestock producers. The NDs
such as Chagas disease and neurocysticercosis are one of
the principal causes of morbidity and disability in these
populations. The PHM Initiative includes a significant
component of health promotion to ensure access to

health services for producers and agricultural workers.
The PHM Initiative promotes integrative, inter-programmatic, and inter-sectoral collaboration; "The activities of
primary health care should wrap, in addition to the health
sector, all the sectors related to local development, in particular to the local government, to the agriculture, production of food, industry, education, housing, public
activities, communication, and other sectors and it
requires the coordinated efforts of all of those sectors"
[49]. This model is based on a systematic approach that
integrates the agricultural sector with a rural social structure (including health, environmental sustainability and
culture) by emphasizing the importance of "productive
family units" [49].
Effects of microdams and irrigation projects on NDs
Similar to the case of large dams, research in several countries examining the impact of microdams and irrigation
projects has shown that these projects can contribute to an
increase in favorable environmental conditions for the
transmission of parasitic diseases during the dry season,
specifically schistosomiasis, intestinal helminths and
malaria [50,51]. The number of people living in close
proximity to small dams and informal irrigation remains
elusive, which inevitably results in an underestimate of
the total number of people at risk for parasitic diseases
due to water resources development [52]. Health safeguards must be incorporated into the planning, construction and operation of microdams and irrigation systems
meant to serve agricultural and livestock producers, as
well as larger dams used principally for hydropower and
flood control, in order to prevent and reduce these diseases.
For example, recent research on food security and disease

transmission suggests that over the last three decades the
agricultural-irrigation network has extended globally,
thus ensuring water security and increasing the area of arable land that could be farmed by intermittent wet/dry irrigation (IWDI) [53]. As a result of this expansion, malaria
vector breeding was proven to have been greatly reduced,
representing a significant opportunity for synergy by maximizing agricultural productivity while increasing protective factors for those living in rural communities [54].
Effects of deforestation and rural colonization
Various economic forces in LAC drive the clearing of forests including cattle ranching, soybean farming, gold mining, hydroelectric dams, and expansion of subsistence
agriculture and road construction. In the case of the latter,
a recent study in the Peruvian Amazon [55] found that
roadside settlements in areas deforested by subsistence
farmers experienced up to 278 times higher mosquito-bit-
Page 7 of 21
ing rates by the local principle malaria vector Anopheles

darlingi than those settlements without deforestation. The
same area has experienced an upsurge in malaria at the
same time, very probably associated with the on-going
deforestation. As well, several NDs such as leishmaniasis
and Chagas disease are associated with deforestation and
rural decolonization. When these diseases are coupled
with a lack of access to health services for rural populations it results in a deterioration of the populations health
status, further hampering rural agricultural worker productivity and rural family health. As these areas are further
developed, strategies to control malaria and other diseases
require a combination of preventive and curative methods
well as close collaboration between the health and agricultural sectors [56].
High risk rural populations and protective measures
Malnutrition, diarrhea, anemia and other complications
of soil-transmitted helminth infections will often lead to
stunting and school absenteeism [57], and probably
reduce family economic productivity over the life cycle in
both rural and urban areas. High risk rural populations
affected by soil-transmitted helminths and other NDs
include migrant agricultural workers, itinerant gold miners in Brazil [58], and those living in agricultural labor
camps and plantations (e.g., Guatemalan and Mexican
coffee pickers with onchocerciasis) [59]. These high disease transmission environments may be mitigated by
improved health services including necessary drug treatment, better access to food and micronutrients, and
micro-enterprise development to increase incomes which
in turn can allow increased individual and family access to
health care services. A specific strategy will have to be tailored to the local conditions, partners, community needs,
and resources available in the community. Examples of
activities that could be integrated in high risk populations
include:
The promotion of household level food production

for nutrition and food security, with both de-worming
and Vitamin A supplementation [60]
In trachoma-endemic areas one could add the elements of the trachoma SAFE interventions (Surgery,
Antibiotic Therapy, Facial Cleanliness, and Environmental Improvement) with care for skin diseases
Addressing key micronutrient deficits [61] (e.g., zinc
deficiency which is casually associated with diarrhea,
pneumonia and malaria in children under age 5 [62])
can be accomplished by adding micronutrients to key
foods in the local diet or to condiments such as table
salt
In areas endemic for lymphatic filariasis, diethylcarbamazine (DEC) is added to table salt for mass treatment of at-risk populations and has the potential to
eliminate transmission within one to two years. DECsalt can be combined with iodine and fluoride, as is
being utilized in Guyana.
The major challenge ahead is to ensure food security while
increasing protective factors for the tens of millions of
families living in poverty in LAC. This large and complex
task involves increasing agricultural output worldwide,
reducing poverty, and improving health and nutrition.
These activities have the potential to bolster the productive family units by generating more income and protective factors associated with the rural environment.
Developing countries need to improve access to food
while also increasing the protective factors of the population by providing education and health services and fostering local participation across sectors.
III. Community Driven Development

Community participation approaches help to build social
capital and prove to be an efficient mechanism for delivering micro-projects which become productive investments. Community participation has been propagated
through various initiatives and institutions in development. One such approach is the concept of Community
Driven Development (CDD) which the World Bank has
intricately linked to various issues of rural and urban services. "Poor people are often viewed as the target of poverty
reduction efforts, CDD approaches by contrast, treat poor
people and their institutions as initiators, as collaborators
and as resources on which to build" [63]. CDD is broadly
defined as giving control of decisions and resources to
community groups. With a view to generate sustainable
and wide ranging impacts, CDD operations and regional
strategies have increasingly embraced two important pillars of sustainability and scale: linking communities to the
private sector and to local governments.
Interventions should be tailored to local conditions
Identification of country specific issues is crucial in
designing appropriate CDD approaches to development
projects and health interventions. In most projects the
entry point for local development has often been the
project implementation stage rather than the project preparation stage. "In order to enhance the application of
CDD approaches in the earlier stages of the project life
cycle, additional time and financial resources are needed
so that communities can be mobilized and involved in the
design and decision making of the overall project framework and components" [63]. By making investments
responsible to informed demand, communities are better
able to weigh tradeoffs and make realistic choices to fit the
local conditions.
Page 8 of 21
The nature of the connection between health and socioeconomic development has become much more evident
within the CDD approach. Family health, economic security, environmental sanitation and income generation, all
have crucial implications at the local level for combating
communicable diseases and the NDs. CDD complements
integration, inter-programmatic and inter-sectoral collaboration by emphasizing community ownership and
engaging relevant stakeholders in order to garner broadbased support and achieve sustainability.
However, the need remains for greater attention towards
the formulation of public policies that will effectively contribute to improving the quality of life for the population,
while at the same time promoting equity. In addition, the
recent trend of decentralization should lend itself to
greater accountability for decision-making and vertical
collaboration.
There are several good reasons for the ND agenda to be
linked with CDD approaches:
Efficiency: A better fit between program design and
community needs that span across sectors through the
introduction of basic public health preventive measures, such as education, clean water and sanitation
Equity: Greater community contributions allow marginalized portions of the population to receive information and provide input toward public health
decision-making
Accountability: Greater accountability of the programs to communities with greater transparency with
mechanisms for local participation built in to institutional design
Sustainability: Greater sustainability because of community ownership through the contribution of local
resources for maintenance and improvement
CDD at work: river blindness in West Africa
An illustration of the CDD approach is the conquest of
river blindness in West Africa. River blindness, or
onchocerciasis, has virtually been eliminated in 11 countries with a population of 34 million people [64]. This
monumental achievement was made possible by country
specific CDD approaches that focused on an appropriate
division of labor between central governments and local
communities. In this instance, large-scale vector control
activities were carried out by the government, while local
communities managed the distribution of the antihelminthic drug ivermectin to fight the disease [64]. Community-based ivermectin treatment programs in West
Africa supported by vector control have saved the sight of
600,000 people, spared 15 million children from living in

at-risk environments, and opened up 25 million hectares
of arable land for agriculture [64].
To further ensure institutional sustainability of community based programs, there is a definitive need to link
these projects to local governments. PAHO has provided
a framework for linking the CDD approach to local governments through the encouragement of health promotion and the Healthy Municipalities and Communities
Initiative.
IV. Healthy Municipalities and Communities

Initiative
The Healthy Municipalities and Communities (HMC) Initiative is part of PAHO's Healthy Settings approach and
essentially consists of two components; the commitment
towards health promotion by local authorities, and the
active participation by the community. The strategy
encourages health interventions that are highly cost-effective, not only in the case of infectious diseases, but
chronic diseases as well. In the HMC Initiative, local
development is designed with a focus on building partnerships between local authorities, community leaders
and organizations, and private and public sector institutions. Social participation is critical throughout all phases
of the process, including the needs assessment, planning,
implementation, monitoring and evaluation phases. It
helps to create synergy among programs, horizontally and
internally within local government structures, and vertically with national and regional priorities. The "Healthy
Cities" initiative, which the WHO promoted in Europe
and Quebec, Canada, has prompted the countries of LAC
to adapt the idea to the local level, municipalities and
communities [65].
Community-based, integrated health promotion
The most successful integrated, inter-sectoral efforts to
date have proven to be those that incorporate concrete,
community-based initiatives. To be effective, any integration mechanism must place broad-based emphasis on
health protection and health promotion [66]. In these
environments health promotion serves as the mechanism
to build multi-sectoral partnerships and strengthen social
participation to upgrade the living and working conditions of the population. This is accomplished with a sustainable process of local planning with health and
development targets which are agreed upon among all
stakeholders [67]. Thus local development plans respond
to the needs and aspirations of local residents, leaders and
other stakeholders. The synergy this process creates allows
for several targets to be addressed together, rather than
developing a plan for each identified issue.
Page 9 of 21
The idea of health promotion in conjunction with community mobilization has particular significance for the
ND agenda. By utilizing social participation and community organization, the multi-faceted determinants of disease can be addressed locally through multi-sectoral
cooperation. In the case of lymphatic filariasis and soiltransmitted helminthiasis for example, a community will
be better equipped to identify and address problems
related to unclean water and harmful sanitation practices
that are propelling transmission of these diseases. In addition, a more comprehensive base of support initiated
through community awareness of the problem, helps to
ensure that any health promotion efforts are sustainable
over time and across various sectors. In this context, smallscale administrative and political units may provide a
more flexible environment for the implementation of
inter-sectoral actions, as recommended by HMC.
The main objective of health promotion is to give people
greater control over their own health. To achieve this goal,
health promotion must transcend the boundaries of the
health sector. The health promotion strategy contributes
to an improvement in the health status of the population,
while simultaneously bolstering activities that mobilize
other sectors, such as education. In further recognition of
health promotion's critical role in responsive governance,
all countries of the Americas signed the Mexico Declaration (Fifth Global Conference on Health Promotion
2000) which embodies a commitment to implement
national health promotion plans of action at local and
national levels.
Principal areas of health promotion
The Ottawa Charter for Health Promotion and the Declaration of the International Conference on Health Promotion (the latter held in Santa fe de Bogota, Columbia)
identify the following as the principal areas of action for
health promotion [68]:
1) The formation of a public health policy that goes

beyond the curative dimension, which implies an
inter-sectoral view that allows for action on the part of
the population, health services, health authorities, and
the productive social sectors
2) Creation of environments that will foster good
health in its physical, environmental, and social
aspects through the promotion of healthy communities
3) Strengthening (empowering) of community action
in health, since organized community participation
facilitates the identification of needs and priorities in
order to modify the situation and raise the level of
well-being
4) The development of personal skills that give individuals control over their health and environment in
order to reduce risk factors for morbidity
5) Reorganization of health services to give priority to
health promotion and disease prevention (and tailoring them to specific sociocultural contexts when
appropriate)
6) Identification and reduction of the factors that lead
to inequity
Linking local government to health promotion
The HMC Initiative encourages the participation of government authorities and the community through promoting dialogue and fostering collaboration among
municipalities and communities [69] and influencing
policy development.
HMC strategies encourage the creation of Inter-Sectoral

Committees for health promotion in municipalities, with
the leadership of the Local Inter-sectoral Committees and
the Mayors. These strategies outline provisions for the
mobilization of resources, securing adequate support and
technical cooperation, and creating healthy and supportive environments in schools, workplaces and public
spaces.
Examples of HMC at work
Current examples of the HMC Initiative at work include
efforts in the rural Municipality of Chopinzino, Brazil
where inter-sectoral action, combined with strong community participation, helped to broaden the scope of the
local council beyond agricultural activities in the rural sector. Under the HMC project the level of education was
increased by bringing schools together to improve school
transportation, adopting alternative teaching techniques,
and a pledge to guarantee education opportunities for all
children living in rural areas. In collaboration with the
increased dedication to rural education, the project also
offered various programs to promote health including:
efforts to combat infant mortality, family planning, diabetes prevention and blood pressure monitoring [69].
In the small Canton of San Carlos, Costa Rica the local

government initiated the Ecological and Healthy Canton
project to bring together various sectors (economic,
social, health, education, social welfare, transportation,
communications and media) to design a strategy to make
the canton a model for health promotion. The project
encouraged the active participation of community members in the promotion of health through environmental
projects and resulted in greater coverage of environmental
education through the media and an "Inter-sectoral
Health Fair" held under the slogan of "Protect our Envi-
Page 10 of 21
ronment" [65]. In such projects, entry points can be created to promote the prevention and control of the NDs of
local importance.
It is critical that projects utilizing the HMC Initiative contain a specific ND component. For example, it is estimated
that 20 to 30% of the population of the Americas is
infected with the intestinal worms Ascaris lumbricoides, Trichuris trichiura, and/or human hookworm and Schistosoma
mansoni [70]. Parasitic worms disproportionately affect
children and compete with the child for nutrients, causing
anemia and impairing the growth and development of the
child, which contributes to a poor quality of life [57]; they
also lower the work capacity of adults. Through the
involvement of schools and workplaces the HMC strategy
can reduce the intensity and prevalence of these parasitic
diseases in the community. Evidence demonstrates that
the morbidity caused by intestinal parasites can be greatly
reduced by comprehensive community-based programs.
Management of these programs can be established with
control activities being undertaken through existing
health facilities and the education sector. The strategy is
based upon the integration and inter-sectoral efforts to
deliver periodic chemotherapy (once or twice a year
depending upon the prevalence and worm burden in the
area) to schoolchildren in high-risk areas, intense health
and hygiene education, and improvement of sanitation
and a safe water supply. In one particular study, the results
of this method demonstrated an overall reduction in prevalence of parasitic infections of 44%, illustrating the HMC
strategies potential to drastically reduce the burden of parasitic diseases among specific populations. By incorporating a ND component in health promotional activities the
community will be better sensitized to the problem and
its determinants which can begin to break the cycle of illhealth and poverty.
The HMC Initiative represents an excellent opportunity to
coordinate the needs identified by the local community
within the broader framework of health promotion.
Under this strategy, health promotion acts as the vehicle
for linking the various sectors (i.e., environment, agriculture, health, education) for the common goal of promoting health and addressing the underlying determinants
that govern health.
Today children, adolescents, and young people require an

education for life aimed at the development of their
innate capacity to learn to be, learn to learn, learn to do,
learn to live with others, as well as to learn to undertake
actions. For this, there is the need for the implementation
of participatory education to develop students' analytical
and inquiring capacity, and to strengthen their principles
of respect for human rights, equity, and collective values.
Schools have the responsibility for the implementation of
health related activities. Traditionally, these activities have
been characterized by ad hoc efforts, mostly directed to
improving conditions of hygiene and environmental sanitation, preventing communicable diseases, treating specific diseases, and performing sporadic medical
examinations or screening tests. As a result of the health
and education sector reforms, being implemented by the
majority of countries in the Americas, Health Promotion
strategies are now being implemented in the school setting, thus creating new opportunities for the implementation of comprehensive school health programs
throughout the Region.
The HPS Regional Initiative proposes the use of health
promotion strategies that apply theories, models, and
tools with solid scientific bases. PAHO/WHO formally
launched the Initiative in 1995, in response to countries'
needs and priority for comprehensive and sustainable
school health programs, and as a commitment to Health
Promotion in the school setting [71]. The Initiative is
based on a comprehensive conceptual framework, with a
multidisciplinary and multisectoral approach that considers people in the context of their daily life, within their
family, their community, and their society.
HPS promote the development of knowledge, abilities,
and skills to allow individuals to care for their health and
that of others, to minimize risk behaviors and especially
to adopt and maintain healthy lifestyles [72]. The Initiative contributes to the establishment of equitable social
gender relationships, encouraging civic spirit and democracy, and strengthening the traditions of solidarity and
community participation. It advocates for the promotion
and protection of human rights and fundamental
freedoms in schools and surrounding communities. As
such, also contributes to the MDGs.
V. Health-Promoting Schools Regional Initiative

The Health-Promoting Schools (HPS) Regional Initiative
is also part of PAHO's Healthy Settings approach. As such,
it advocates for Health Promotion strategies in the school
setting to improve the health and well-being of students
and the school community, including teachers, families
and the surrounding school population.
A regional survey in 19 Latin American countries [73]

showed that 94% of the countries were developing the
HPS strategy. In almost all cases (90%), the HPS strategy
is being implemented in public primary schools in urban
areas. 82% of the countries have school health plans predominantly in primary schools. 94% of the countries have
policies aimed at health promotion of the school-age population, and 82% have specific policies related to the
Page 11 of 21
Health-Promoting Schools strategy. 30% of the countries

have designated budgets to finance school health programs. NGOs (national or local) support the financing of
such activities in 71% of the cases. About one-third of the
countries (29.4%) received loans or financing from international organizations to support school health programs. These data, together with other vital information
from the countries, as well as information from case studies and countries' visits provided the foundation for the
development of the Plan of Action 20032012 for the
Health-Promoting Schools Regional Initiative [74].
The Health-Promoting Schools Regional Initiative is composed of three main components [74]: comprehensive
health education, including Life Skills training; healthy
physical and psychosocial environments; and health and
nutrition services and active life. The comprehensive
Health Education component, which includes Life Skills
training, is directed to strengthen the capacity of children,
adolescents, and youth to acquire and utilize knowledge,
attitudes, values, skills, and competencies necessary to
promote and protect their own health and that of their
families and communities. 88% of Latin American countries include Health Education as a transversal element of
their school curricula [73]. Subjects covered by the health
educational activities include addictions (94%); personal
hygiene, sexual and reproductive health, physical education and sports (88%); HIV/AIDS, food and nutrition, utilization of health services (82%); and self-esteem,
immunizations, waste management, and life skills (70%).
Most Latin American countries include physical exercise
and recreation.
The creation and maintenance of healthy school settings
and surrounding environments, the second component of
the Initiative, must guarantee minimum conditions of
safety and environmental sanitation conducive to the
health, well-being, and development of the maximum
potential of children and other members of the educational community. 70% of the countries have policies to
prevent smoking in schools, and 64% have programs to
prevent violence in the school setting. There are major disparities among the countries of the Region with regard to
the number of schools with access to water and drinking
water, and in at least half of the countries where this information is available, the coverage of these services is low or
unsatisfactory [73].
The third component, access to health and nutrition services and active life in the school setting, aims to the development of planned and organized activities that respond
to the needs and priority of students and the educational
communities. 76% of countries have established guidelines about health services to be provided to the school
population, which almost always include periodic medi-
cal controls, vaccination and, to a very limited extent,

other interventions such as early detection of scoliosis,
psychological counseling, and gynecological care [73].
Member States, under the auspices of the HPS Regional
Initiative, are developing Regional Guidelines for certification and accreditation of HPS. These Guidelines will
facilitate the strengthening of school health programs and
activities throughout the Region to ensure the quality and
sustainability of the planning, implementation, and evaluation of Health Promotion strategies in the school setting [73].
A Health-Promoting school is a school that [74]:
Implements policies that support dignity and individual and collective well-being and offers multiple
opportunities for the growth and development of children and adolescents within the context of learning
and success of the school community (including educators, students, and their families);
Implements strategies to promote and support learning and health, utilizing all means and resources available for this purpose and involving personnel from
the health and education sectors and community leaders in the implementation of planned school activities
(e.g., comprehensive health education and Life Skills
training; strengthening of protective factors and reduction of risk behaviors; facilitation of access to school
health services, nutrition, and physical education);
Involves all members of the school and community
(including teachers, parents, students, leaders and
non-governmental organizations) in decision-making
and the implementation of interventions to promote
learning, encourage healthy lifestyles, and carry out
health promotion projects in the community;
Has an action plan to improve the physical and psychosocial school environment and surroundings (e.g.,
standards and regulations for school environments
free from smoking, drugs, abuse, and any form of violence; access to safe drinking water and health facilities; nutrition services), trying to set a good example
through the creation of healthy school environments
and the implementation of activities planned outside
the school setting aimed at the community;
Implements actions to evaluate and improve the
health of students, the educational community, families, and members of the community in general, and
works with community leaders to ensure access to
nutrition, physical activity, counseling, and health and
referral services;
Page 12 of 21
Offers relevant and effective training and educational materials to educators and students; and
Has a local committee on education and health with
the active participation of parents associations, NGOs,
and other organizations in the community.
LAC network of Health-Promoting Schools
Health-Promoting Schools Networks in LAC offer unique
opportunities to continue the dialogue on health promotion and health education in all settings, and to facilitate
the sharing of ideas, resources, and experiences to nurture
the commitment and enthusiasm of school health personnel and experts dedicated to improving Health Promotion programs and activities in the school setting.
The Latin American Network of Health-Promoting

Schools originated at the First Meeting of the Network, in
1996 in San Jos, Costa Rica [75]. The second meeting was
held in Mexico in 1998; the third meeting in Quito, Ecuador, in 2002 [76]; and the fourth meeting in San Juan,
Puerto Rico in 2004 [77].For the Caribbean countries, the
first constitutive meeting of the Caribbean Network of
Health-Promoting Schools was held in 2001, in Bridgetown, Barbados [78]. As of 2002, 29% of the countries had
created national networks of HPS. All Latin American
countries and 14 Caribbean countries are currently participating in the LAC Networks of Health-Promoting
Schools.
Planned strategies for strengthening Health-Promoting
Schools in the Americas
Member States, under the auspices of PAHO/WHO, have
defined six major strategies and pertinent lines of action
for the period 20032012 [74]. The six strategies and
respective lines of action for 2003 to 2012, channeled
through the three components of the Health-Promoting
Schools, are firmly supported by healthy public policies
that facilitate the implementation of school health programs and activities that aim to sustainable human development. The six strategies are:
1. Advocacy for comprehensive school health programs and the Health-Promoting Schools
2. Institutionalization of the Health-Promoting
Schools strategy and formulation of healthy public
policies in the educational communities
3. Strengthening participation of key actors in the
management of school health programs
4. Strengthening the capacity of Member States to
manage the Health-Promoting Schools Initiative
5. Research, evaluation, and surveillance systems for

the development of comprehensive school health programs
6. Mobilization of resources
In summary, as a result of the health and education sector
reforms being implemented by the majority of the countries in the Americas, Health Promotion strategies are now
being implemented in the school setting, thus creating
new opportunities for the creation of comprehensive
school health programs throughout the Region. The HPS
regional initiative offers an important entry-point for the
ND agenda, through the Education and Health sectors,
which can strengthen countries' capacity for the planning
and implementation of comprehensive school health programs, such as Health-Promoting Schools, which will
facilitate the processes for addressing ND, including
deworming programs in the school setting.
VI. Primary Environmental Care Strategy

The most pressing environmental health problems today,
in terms of deaths and illness worldwide, are those associated with poor households and communities in the developing world [79]. In rural areas and in the peri-urban
slums and shanty-towns of the developing world, inadequate shelter, overcrowding, lack of clean water and sanitation, contaminated food, and indoor air pollution are
by far the greatest environmental threats to human health
[80]. The outcome of these threats becomes abundantly
clear in the high rates of infectious disease and disability
that developing communities face.
Primary Environmental Care (PEC) combines the original
strategy proclaimed at Alma-Ata of primary health care
and the conception of integral rural development that
emerged from the agrarian policies of Third World countries during the 1970s. Within the renewed goal of health
for all in the 21st century, the PEC strategy may be considered as all those actions necessary to improve and protect
the local surroundings through foresight and prevention
of possible problems, with tasks institutionalized at the
local level [81].
According to WHO and the World Bank, environmental
improvements at the household and community level
would make the greatest difference for global health [82].
Specifically, the World Bank has calculated that improvements in local environmental conditions facing the poor
could lower the incidence of disease by up to 40% [82].
Agenda 21
In the 1992 United Nations Conference on Environment
and Development, 179 governments adopted Agenda 21,
a comprehensive plan of action that concerns all human
Page 13 of 21
actions that impact the environment. It states the following: "Major adjustments are needed in agricultural, environmental, and macroeconomic policy, at both the
national and international levels, in developed as well as
developing countries, to create the conditions for sustainable agriculture and rural development. The major objective of sustainable agriculture and rural development is to
increase food production in a sustainable way and
enhance food security. This will involve education initiatives, utilization of economic incentives and the development of appropriate and new technologies, thus ensuring
the stable supplies of nutritionally adequate food, access
to those supplies by vulnerable groups, and production of
markets; employment and income generation to alleviate
poverty; and natural resource management and environmental protection" [83].
posal systems, water manipulation in dams and irrigation

systems for vector control, vector diversion by zooprophylaxis, and vector exclusion by improved housing [84].
In response to Agenda 21 many countries in LAC developed national frameworks which provide for the consideration of health, environmental and sustainable
development issues. In trying to work within these frameworks, it is increasingly evident that the process of integrating health with environmental determinants in
sustainable development decision-making is truly an
inter-sectoral task. Success depends on coordination
among numerous organizations, departments and groups
at the international, national, and local levels.
Another area in need of inter-sectoral environmental

action through PEC concerns water use. Agricultural water
users must increase the efficiency of water use, as competition between this sector and urban, industrial and residential users of water resources continues to increase
[15,54]. Natural resource planning and comprehensive
water and natural resource management that rely on a
community-based approach have proven successful in the
past [54,84].
Examples of inter-sectoral environmental action

Worth noting are the experiences in basic sanitation of
large and mid-sized cities. The development of these systems is not only effective with regard to health and urbanization, but also efficient and equitable [85]. The
efficiency is achieved through autonomous and decentralized management of the companies that provide water
supplies and sewage services, while equity results from the
generalized application of progressive rates for these services and general local level participation [85], and PEC
may be the vehicle to stimulate their establishment and
maintenance to serve all communities.
Environmental sector and NDs

The environmental sector is a prime example of an area
that has traditionally been disposed toward inter-sectoral
action and has the ability to lower the burden due to NDs.
Analysis and practice of this strategy are based on a model
focused on the promotion of human beings, the environment, and social development. This operational framework encourages participation and action, thus endowing
individuals, communities, and societies with the power to
make decisions [81].
PEC in action
In 1999, the Pan American Center for Sanitary Engineering and Environmental Sciences (CEPIS) and the PAHO/
WHO Country Office in Peru, began to focus on promoting PEC as a strategy for fostering healthy municipalities
and communities. A broad scope of action was designed
with a series of pilot projects aimed at building local environmental-management capacity in Peru and Central
America. The aim of these pilot projects was to strengthen
communities resolve for recognizing and controlling environmental factors harmful to health.
Initiatives that derive from an environmental paradigm

allow for several entry points for a reduction in the burden
of NDs. Because of the strong causal relationship between
most NDs and environmental factors, PEC can increase
awareness and foster integration of interventions that
have strong implications for both the health and environmental sectors. It allows for stakeholders to identify key
problems affecting their community and to develop sustainable solutions. The previously mentioned HMC Initiative draws heavily on a foundation of environmental
considerations as primary health concerns.
By supporting programs to strengthen the environmental

health agenda, PAHO also sought to strengthen the leadership and advisory capabilities of the region's health
ministries and improve community mobilization and
inter-sectoral coordination. This task involved bringing
together Ministries of Health and Environmental Affairs at
such meetings as the Special Meeting of the Health Sector
of Central America (RESSCA), where plans were approved
for the seven Central American countries as well as the
Central American Plan for Health and Environment in
Sustainable Human Development [86].
Strategies that fall under the umbrella of PEC include the

suppression of vector populations through the provision
and storage of safe water supplies, solid waste management systems, safe and adequate sewage and excreta dis-
In this context, water supply, sanitation and hygiene promotion programs are seen as a cohesive agenda, directly
addressing the needs of the local population. Comprehensive sanitation improvement is not possible in isolation
Page 14 of 21
from other sectors, and special note should be taken of the

relationships among water supply, sanitation and hygiene
behavior change and their synergistic impact on health,
particularly in relation to NDs and dengue and diarrheal
diseases in marginalized populations. The environmental
conditions associated with these diseases have served to
further exclude severely affected populations from the
social systems constructed to safeguard health as a fundamental human right [87]. These overlooked environmental factors have been directly responsible for perpetuating
the cycle of poverty and reducing the quality of life for
millions of people [88], and PEC is an effective tool to
promote and address attention to these environmental
health problems of the poor.
VII. Inter-Sectoral Cooperation: Health and

Agriculture
Inter-American Meeting at the Ministerial Level on Health
and Agriculture (RIMSA)
The importance of collaboration and the strengthening of
partnerships between the health and agriculture sectors
have also been recognized by PAHO. Every two years
PAHO convenes the Ministers of Agriculture and Health
as key representatives to engage in and foster technical
cooperation and technology transfer, at the Inter-American Meetings at the Ministerial Level on Health and Agriculture (RIMSA). In recent years the RIMSA meetings have
also included the Ministries of Environment and the Ministries of Tourism.
These meetings provide efficient mechanisms for the

adoption of multilateral and regional agreements, which
recognize the complementary nature of health and agriculture, regarding such topics as food protection, food
safety, livestock production, tourism and trade. Specifically, RIMSA serves to fortify and institutionalize intersectoral collaboration between the agricultural and health
sectors. This entails, for example, the development of integrated food protection programs by passing international
resolutions in a policy and technical forum for the Americas [89,90].
Some of the technical topics on the agenda include
healthy markets, food safety legislation, food safety based
market improvement, food hygiene training for consumers, food handlers, and market vendors, and promotion of
rural small household production. The meetings provide
an opportunity to develop regional solutions and overarching policies to deal jointly with issues that affect local
and national economies. Many of the topics and subsequent resolutions have a profound impact on public
health.
Neglected zoonoses
One main theme in the 2005 RIMSA meeting was that of
neglected zoonoses in neglected populations. The WHO
Expert Committee defined zoonoses as "those diseases
and infections which are naturally transmitted between
vertebrate animals and man" [91]. Some of the neglected
zoonoses include plague, yellow fever, leptospirosis,
bovine tuberculosis, brucellosis, leishmaniasis, Chagas
disease, schistosomiasis japonica, and taeniasis/cysticercosis (Taenia solium). Neglected zoonoses disproportionately affect vulnerable populations, such as the rural poor.
In many of these marginalized populations agriculture
and human-animal interaction represent not only a
means of income generation, but a means of day to day
survival for individuals, families and communities.
These diseases represent significant public health safety

concerns for the global population because of growing
concerns about the risk of increased transmission. In addition to direct transmission, a growing number of diseases
are transmitted to humans from animal reservoirs via
food consumption, animal products, and human and animal waste [92]. For example, research demonstrates high
levels of cysticercosis in rural Bolivian populations due to
several multi-sectoral human risk factors, including
absence of sanitary facilities, poor formal education and
an inability to recognize infected pork [93]. Also, in the
Andean highlands of South America, research indicates
that fascioliasis (infection with the trematode parasite Fasciola hepatica) is a highly-endemic disease, where human
prevalence rates are the highest known in the world due to
a multitude of sheep, cattle, pig, and donkey reservoir
hosts [94].
This implies that all sectors agricultural, health, education and veterinary must be guided in their work by a
multidisciplinary and inter-sectoral approach, with full
community participation. There can be no doubt that animal health has a vital role in improving the quality of
human life especially in rural populations. Per the "one
health" concept, an integrated human and animal-health
system for specific mobile and remote sedentary populations enhances zoonoses detection and control, and offers
a novel perspective for strengthening and shaping health
systems in hard-to-reach rural communities [95,96]. This
inter-sectoral approach represents an excellent opportunity for building a sense of personal and community
responsibility for the promotion, care, and restoration of
health.
Veterinarians and public health workers frequently interact with the rural population while caring for community
health and livestock needs, as this is an integral part of the
rural socioeconomic structure. Through these interactions
close bonds of trust can be established, not only with
Page 15 of 21
farmers, but with entire families and the community.

These individuals are well placed to enlist community
participation in a variety of veterinary and public health
activities such as zoonoses control, hygiene programs, and
sanitation activities.
To this end, the macro policy environment created by
RIMSA has the potential to serve as an entry point to foster
collaboration between the veterinary, agriculture sectors
and the public health sector at the local level to address
the NDs. In addition to promoting inter-sectoral collaboration in schools of veterinary medicine, some authors
have called for the continuation and expansion of healtheducation programs to train veterinary personnel for work
in other public health fields [97].
Because rural households have so many different sources
of income, rural development policies must go beyond an
agricultural or a singular sector approach. Instead, rural
development and poverty must be addressed as part of a
comprehensive integrated and inter-sectoral approach
that encompasses the dynamics of rural life, taking into
account the interactions between health, agriculture, animal food production, and development. The RIMSA
meetings represent new opportunities at the policy level
to combat the NDs as contributors to rural poverty and to
foster rural development and inter-sectoral collaboration
as a result of an increasingly dynamic agriculture sector,
greater decentralization, and more forms of participatory
governance.
VIII. Public Health and Human Rights

Vulnerable groups often suffer discrimination within a
society; among them are the victims of such NDs as leprosy and lymphatic filariasis. In addition, they are sometimes subject to inhuman or degrading treatment and
restrictions regarding their freedom of movement and
their right to live and work in a healthy environment.
Such treatment constitutes a violation of their basic
human rights and fundamental freedoms, including the
right to health, understood as the right to enjoy (without
discrimination) health services, facilities and goods that
are available, accessible, and of good quality.
The vulnerability, powerlessness and abandonment that
are frequently experienced by those living with NDs
require urgent actions and strategies. Although legally
protected by national and internationally recognized
human rights instruments, the human rights of vulnerable
populations, especially health-related rights, are often
ignored. PAHO/WHO believes that understanding these
rights and ensuring that they are respected according to
international human rights obligations is an essential step
in the treatment of epidemics, illnesses and disability and
an integral part of the promotion and protection of public
health and disease prevention. Thus, international human

rights law is an essential tool that supports Member States
with:
The recognition, promotion and protection of the
right to health and other health-related rights and fundamental freedoms, in accordance with international
human rights instruments that have been ratified by
PAHO/WHO Member States
The improvement of living conditions and standards
of care in health facilities and services
The strengthening of national agencies responsible
for monitoring compliance with international human
rights norms (including the right to health), such as
the Ombudsman offices
The formulation/reform of health plans, policies
and legislation according to international human
rights norms and standards
The collaboration with international human rights
bodies such as the Inter-American Commission on
Human Rights of the Organization of American States
(OAS) and the UN Committee on Economic, Social
and Cultural Rights and the UN Special Rapporteur on
the Right to Health; particularly with regard to the full
realization of the right to health in connection with
other basic human rights and freedoms
The adoption of legislative, judicial, administrative,
educational and other means to promote and provide
accessible primary health care, community based services, health facilities and goods
The elimination of the stigma and discrimination
associated with persons who are experiencing health
problems, illnesses (including the stigmatized NDs),
epidemics and disability
A more cohesive human rights strategy that is consistent
with the international and regional human rights binding
instruments and standards is essential to continue to
develop the aforementioned actions and to formulate
new initiatives on human rights according to WHO guidelines. In summary, the purposes of the aforementioned
initiatives are to:
Advance and clarify the conceptual framework of
human rights law as an instrument that can be used in
all aspects of PAHO's work and across the Organization in order to accomplish PAHO's mission
Page 16 of 21
Ensure consistency in approaches, messages, human

rights instruments and guidelines recommended by
PAHO and WHO.
Address the human rights and fundamental
freedoms of vulnerable groups (in particular the right
to health and health-related rights) in connection with
health problems including NDs, illnesses, disability,
epidemics, and access to health services.
analyze and respond to the extra-sectoral factors driving

health conditions and then offer alternatives for coordinating inter-sectoral action. This requires the adaptation
or development of new technologies, the establishment of
new organizational frameworks within the context of
decentralization, emphasis on integration through primary care and health promotion, and the modification
(growth) of the professional profile of health care workers
by overall improvement of managerial, technical and
political skills.
Summary
The persistence of the "vicious circle" between poverty
and poor health demonstrates the importance of linking
the activities of the health sector with those of other sectors such as education, housing, water and sanitation,
labor, public works, transportation, agriculture, environment, and industry and using human rights norms and
guidelines. The challenges presented by the prevention
and control of the NDs present a significant opportunity
to coordinate these sectors, with the goal of strengthening
partnerships. It recognizes the synergistic impact across all
sectors in improving health, and maintains that none of
the health problems that affect a given population can be
resolved and sustained exclusively by the health services
system itself.
The foundation for this approach is the recognition that
health is influenced by many factors, from genetic inheritance and individual behavior, to societal and family circumstances, and the social and physical environment. The
intimate connection between health and the factors outside the purview of the health sector makes it an essential
priority to pursue integration and establish inter-sectoral
and inter-programmatic ties in order to further health
development with equity and precision.
This paper has documented several success stories in the
LAC region and provided examples of several PAHO initiatives and one World Bank initiative that have highlighted
the importance of integrative and inter-sectoral
approaches. At the national level, there is a great need to
coordinate these initiatives with macro- and sectoral-level
policy (e.g., sector-wide approaches). Coordination is
necessary among the different international departments
and agencies and within different levels of government, in
order to sustain cooperation. There is still much to be
learned about how to provide incentives for this coordination to take place [98].
Coordination and cooperation will be most effective if
horizontal coordination takes place at all levels (global,
national, local), and particularly at the local level, which
should act as the focal point for defining needs and instigating change to the regional and national governments.
Ministries of Health must also improve their capacity to
Refer to Figure 1 which illustrates the shift needed in policy frameworks from vertical to horizontal, integrated
approaches to ND prevention, control and elimination,
with an emphasis on community-level interventions. The
figure highlights, as examples, the eight initiatives discussed in this document which can be incorporated with
ND prevention, control and elimination.
In addition to these crucial changes within the health sector, other changes must be promoted. Public health data
must be made more prominent on the national political
agenda, and an effort must be made to encourage the
interest and participation of other sectors in health-related
matters. This, in turn, means enhancing the health sector's
capacity for negotiation with the political, legislative, and
budgetary sectors and the national press. In terms of policy instruments, re-channeling of government expenditures toward activities to protect and promote health for
all (including neglected populations) is important, as is
convincing donors to redirect their financial support
toward solving environmental health problems identified
through integrative and inter-sectoral efforts.
Although traditional technological tools exist to combat
certain diseases and health conditions, it is the political
and social commitment followed by the financial investments and innovative strategies that are necessary to take
the process to a higher level. Effective sustainable development and the attainment of the MDGs is simply not possible without mechanisms related to State accountability
(such as those established by human rights treaties) and a
reduction in the burden of diseases that detract from
worker productivity, take away educational opportunities
and create chronic disability among the poorest segments
of the population. Health, including its inter-sectoral and
inter-programmatic dimensions, must be recognized as a
crucial factor that contributes greatly to global social and
economic development, as well as a fundamental right
integral to the attainment of other basic human rights and
liberties.
List of Abbreviations
CDD. Community Driven Development.
Page 17 of 21
Disease-Centered
Approach to
Neglected Diseases
Population Health Approach to Neglected Diseases
Health
of the
Indigenous
Peoples of the
Americas
Program
(PAHO/WHO)
Productive
&
Healthy
Municipalities
(PAHO/WHO)
Community
Driven
Development
(World Bank)
Healthy
Municipalities
&
Communities
(PAHO/WHO)
Health
Promoting
Schools
Regional
Initiative
(PAHO/WHO)
Primary
Environmental
Care
(PAHO/WHO)
Health &
Agriculture
Inter-Ministerial
Conferences
(RIMSA)
(PAHO/WHO)
Public Health
&
Human Rights
(PAHO/WHO)
Shifting
Figure policy
1
frameworks: an integrated, inter-sectoral approach to neglected diseases
Shifting policy frameworks: an integrated, inter-sectoral approach to neglected diseases.
CEPIS. Pan American Center for Sanitary Engineering and

Environmental Sciences.
IWDI. Intermittent Wet/Dry Irrigation.

LAC. Latin America and Caribbean.
DEC. Diethylcarbamazine.
MDGs. Millennium Development Goals.
HIPA. Health of the Indigenous Peoples of the Americas.
NDs. Neglected Diseases.
HIV/AIDS. Human Immunodeficiency Virus/Acquired
Immunodeficiency Syndrome.
NGO. Non-governmental Organization.
HMC. Healthy Municipalities and Communities.
OAS. Organization of American States.
HPS. Health-Promoting Schools.
PAHO. Pan American Health Organization.
IMCI. Integrated Management of Childhood Illnesses.
PEC. Primary Environmental Care.
IUCN. World Conservation Union.
PHM. Productive and Healthy Municipalities.
Page 18 of 21
RESSCA. Special Meeting of the Health Sector of Central

America.
RIMSA. Inter-American Meetings at the Ministerial Level
on Health and Agriculture.
2.
3.
4.
5.
SAFE. Surgery, Antibiotic Therapy, Facial Cleanliness, and

Environmental Improvement.
6.
SEGEPLAN. Secretary General of Development and Planning.
8.
7.
9.
STI. Sexually Transmitted Infection.

UN. United Nations.
USAID. United States Agency for International Development.
10.
11.
12.
WHO. World Health Organization.

13.
Competing interests
The authors declare that though they are employees of the
Pan American Health Organization and the World Health
Organization, the contents of this paper are the sole
responsibility of its authors and should not be construed
as speaking for the policies of the Governing Council of
the Pan American Health Organization and the World
Health Organization. This paper is a contribution on the
important opportunities arising from inter-sectoral and
inter-programmatic dialogue to further international public health programs.
Authors' contributions
MRP conceived the idea of the paper in collaboration with
JPE, and is the principle conceptual author. JCH wrote the
early drafts of the paper with editing by JPE. RR, JV, MTC,
JIS, and MAG later wrote and edited their respective sections of the paper, and SKA added additional content and
edited later versions of the document. All authors
reviewed and approved the final version of the paper.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Acknowledgements
We thank Jose Luis Di Fabio, Heidi V. Jimenez, Albino Jose Belotto, and Luis
A. Cassanha Galvo for their helpful comments and suggestions. We also
thank PAHO's Office of Legal Affairs, Area of Health Services Delivery and
Technology, Area of Environmental Health and Sustainable Development,
and the Communicable Diseases and Veterinary Public Health Units for
their input and participation. JPE and SKA also thank Stephen Corber, formerly PAHO's Area Manager for Health Surveillance and Disease Management, for encouragement to pursue this work. We also thank Monica Palak
and Sabrina Malkani for their efforts editing and formatting the paper.
References
1.
United Nations Development Programme: Human Development

Report 2000 New York; 2000.
24.
25.
26.
27.
Pan American Health Organization, Area of Health Analysis and Information Systems (AIS): Health Situation in the Americas Basic Indicators
2005 Washington, DC; 2005.
World Bank: PovertyNet. [http://www.worldbank.org/poverty/].
World Bank: World Development Report 2000/2001 Washington, D.C;
2000.
United Nations Children's Fund: The State of the World's Children 1999
New York; 1999.
World Health Organization: The World Health Report 2000. Health Systems: Improving Performance 2000 [http://www.who.int/whr/2000].
Geneva
African Development Bank, European Bank for Reconstruction and
Development, Inter-American Development Bank, International
Monetary Fund World Bank: Global poverty report 2000. G8
Summit: 23 July 2000; Okinawa, Japan [http://www.adb.org/docu
ments/reports/global_poverty/2000/G8_2000.pdf].
Collier P: Breaking the Conflict Trap: Civil War and Development Policy
Washington D.C.: World Bank; 2003.
Stewart F: Root causes of violent conflict in developing countries. BMJ 2002, 324:342-345.
Nafziger EW, Auvinen J: The economic causes of humanitarian
emergencies. In War, Hunger and Displacement: The Origin of
Humanitarian Emergencies Edited by: Nafziger EW, Stewart F, and
Vayrynen R. Oxford: Oxford University Press; 2000:91-145.
Homer-Dixon T: Environmental scarcities and violent conflict:
evidence from cases. Int Secur 1994, 19:5-40.
Kaplan R: The coming anarchy: how scarcity, crime, overpopulation and disease are threatening the social fabric of
our planet. Atlantic Monthly 1994:44-74.
Swain A: Water scarcity as a source of crisis. In War, Hunger and
Displacement: The Origin of Humanitarian Emergencies Edited by:
Nafziger EW, Stewart F, Vayrynen R. Oxford: Oxford University
Press; 2000:179-205.
U.S. Government: The National Security Strategy of the United States
(NSS) 2000 [http://www.whitehouse.gov/nsc/nss.html]. Washington,
DC
Rosegrant MW, Paisner MS, Meijer S, Witcover J: Global Food Projections 2020: Emerging Trends and Alternative Futures Washington D.C.:
International Food Policy and Research Institute; 2001.
Pinstrup-Andersen P: Eradicating poverty and hunger as a
national security issue for the United States. ESCP Report 2003,
9:22-27.
World Health Organization: World Health Report 2002 Geneva; 2002.
Brooker S, Alexander N, Geiger S, Moyeed RA, Stander J, Fleming F,
Hotez PJ, Correa-Oliveira R, Bethony J: Contrasting patterns in
the small-scale heterogeneity of human helminth infections
in urban and rural environments in Brazil. Int J Parasitol 2006,
36:1143-1151.
Ehrenberg JP, Ault SK: Debate: Neglected diseases of neglected
populations: Thinking to reshape the determinants of health
in Latin America and the Caribbean. BMC Public Health 2005,
5:. (11 November 2005)
Editorial: Lancet 364:1993-1994. 4 December 2004
World Health Organization: Report of the Third Global Meeting of the
Partner's for Parasite Control: Deworming for Health and Development
Geneva; 2005.
Awasthi S, Pande VK, Fletcher RH: Effectiveness and cost-effectiveness of albendazole in improving nutritional status of
pre-school children in urban slums. Indian Pediatr 2000,
37:804-806.
Mascie-Taylor CG, Alam M, Montanari RM, Karim R, Ahmed T, Karim
E, Akhtar S: A study of the cost-effectiveness of selective
health interventions for the control of intestinal parasites in
rural Bangladesh. J Parasitol 1999, 85:6-11.
Simeon DT, Grantham-McGregor SM, Callender JE, Wong MS:
Treatment of Trichuris trichiura infection improves growth,
spelling scores and school attendance in some children. J Nutr
1995, 125:1875-1883.
Dunford C, Mknelly B: Best practices: using microfinance to
improve health and nutrition security. Global Health Council
Health Link 2002, 118:9-22.
Page 19 of 21
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
Ezeamama AE, Friedman JF, Remigio OM, Acosta LP, Kurtis JD, Mor
V, McGarvey ST: Functional significance of low-intensity
polyparasite helminth infections in anemia. J Infect Dis 2005,
192:2160-2170.
Stoltzfus RJ, Dreyfuss ML, Chwaya HM, Albonico M: Hookworm
control as a strategy to prevent iron deficiency. Nutr Rev 1997,
55:223-232.
Yamey G: The world's most neglected diseases. BMJ 2002,
325:176-177.
Webb K, Hawe P, Noort M: Collaborative inter-sectoral
approaches to nutrition in a community on the urban fringe.
Health Educ Behav 2001, 28:306-318.
Utzinger J, de Savigny D: Control of neglected tropical diseases:
integrated chemotherapy and beyond. PLoS Med 2006,
3(5):e112-.
World Health Organization: Prevention and Control of Schistosomiasis
and Soil-Transmitted Helminthiasis. WHO Tech Rep Ser 2002, 912:.
Hotez PJ, Molyneux DH, Fenwick A, Ottesen E, Sachs SE, Sachs JD:
Incorporating a rapid-impact package for neglected tropical
diseases with programs for HIV/AIDS, tuberculosis, and
malaria. PLoS Med 2006, 3:e102-0584.
Lammie PJ, Fenwick A, Utzinger J: A blueprint for success: integration of neglected tropical disease control programmes.
Trends Parasitol 2006, 22:313-321.
Waddell S, Brown D: Fostering inter-sectoral partnering: a
guide to promoting cooperation among government, business, and civil society actors. Institute for Development Research
Reports 1997, 13:1-22.
Charles C, McNulty S, Pennell J: Partnering for results: a user's
guide to inter-sectoral partnering. U.S. Agency for International
Development. Mission's Directors' Conference: November 1998; Washington, D.C [http://www.usaid.gov/pubs/isp/handbook/guide.html].
Pan American Health Organization: Health of the Indigenous Peoples of
the Americas Program. Proposal: Lines of Work and Action Plan 2005
2015 Washington, DC; 2004.
Miranda RA, Xavier FB, Menezes RC: Intestinal parasitism in a
Parakana indigenous community in southwestern Para
State, Brazil. Cad Saude Publica 1998, 14:507-511.
Ferreira CS, Camargo LM, Moitinho M, de Azevedo RA: Intestinal
parasites in Iaualapiti Indians from Xingu Park, Mato Grosso,
Brazil. Memorias Instituto Oswaldo Cruz 1991, 86:441-442.
Fontbonne A, Freese-De-Carvalho E, Acioli MD, Sa GA, Cesse EA:
Risk factors for multiple intestinal parasites in an indigenous
community of the state of Pernambuco, Brazil. Cad Saude Publica 2001, 17:367-373.
Keiser J, Utzinger J: Emerging foodborne trematodiasis. Emerg
Infect Dis 2005, 11:1507-1514 [http://www.cdc.gov/ncidod/EID/
vol11no10/05-0614.htm#cit].
Beltrame A, Scolari C, Torti C, Urbani C: Soil-transmitted
helminth (STH) infections in an indigenous community in
Ortigueira, Parana, Brazil and relationship with nutritional
status. Parassitologia 2002, 44:137-139.
Scolari C, Torti C, Beltrame A, Matteelli A, Castelli F, Gulletta M,
Ribas M, Morana S, Urbani C: Prevalence and distribution of soil
transmitted helminth infections in indigenous schoolchildren in Ortigueira, State of Parana, Brazil: implications for
control. Trop Med Int Health 2000, 5:302-307.
International Fund for Agricultural Devleopment: Regional Strategy
Paper: Strategy for Rural Poverty Reduction Latin America and the Caribbean
2002
[http://www.ifad.org/operations/regional/2002/pl/
PLeng.pdf]. Rome
World Bank: Reaching the Rural Poor: A Rural Development Strategy for
the Latin American and Caribbean Region Washington, D.C; 2002.
Valdes A, Wiens T: Rural poverty in Latin America and the
Caribbean. In Proceedings of the Second Annual Bank Conference on
Development in Latin America and the Caribbean: 30 May 1996; Washington DC Washington D.C: World Bank; 1996.
Kostov P, Lingard J: Integrated Rural Development Do We Need a New
Approach? 2000 [http://econwpa.wustl.edu/eps/othr/papers/0409/
0409006.pdf]. Belfast: Queen's University
Morales AJ: Productive municipalities and food security at the
local level. Provisional Agenda Item 12 at the PAHO XII Inter-American
Meeting, at the Ministerial Level, on Health and Agriculture: 24 May
2001; Sao Paulo, Brazil [http://www.paho.org/english/ad/dpc/vp/
rimsa12_19-e.pdf].
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
Keiser J, Casto MC, Maltese MF, Bos R, Tanner M, Singer BH,

Utzinger J: Effect of irrigation and large dams on the burden of
malaria on a global regional scale. Am J Trop Med Hyg 2005,
72:392-406.
Alemayehu T, Ye-ebiyo Y, Ghebreyesus TA, Witten KH, Bosman A,
Teklehaimanot A: Malaria, schistosomiasis, and intestinal
helminths in relation to microdams in Tigray, northern Ethiopia. Parassitologia 1998, 40:259-267.
Steinmann P, Keiser J, Bos R, Tanner M, Utzinger J: Schistosomiasis
and water resources development: systematic review, metaanalysis, and estimates of people at risk. Lancet Infect Dis 2006,
6:411-425.
Keiser J, Utzinger J, Singer BH: The potential of intermittent irrigation for increasing rice yields, lowering water consumption, reducing methane emissions, and controlling malaria in
African rice fields. J Am Mosq Control Assoc 2002, 18:329-340.
Qunhua L, Xin K, Changzhi C, Shengzheng F, Yan L, Rongzhi H, Zhihua Z, Gibson G, Wenmin K: New irrigation methods sustain
malaria control in Sichuan Province, China. Acta Trop 2004,
89:241-247.
Vittor AY, Gilman RH, Tielsch J, Glass G, Shields T, Lozano WS,
Pinedo-Cancio V, Patz A: The effect of deforestation on the
human-biting rate of Anopheles darlingi, the primary vector
of Falciparum malaria in the Peruvian Amazon. Am J Trop Med
Hyg 2006, 74:3-11.
de Castro MC, Monte-Mor RL, Sawyer DO, Singer BH: Malaria risk
on the Amazon frontier. PNAS 2006, 103:2452-2457.
Berkman DS, Lescano AG, Gilman RH, Lopez SL, Black MM: Effects
of stunting, diarrhoeal disease, and parasitic infection during
infancy on cognition in late childhood: a follow up study. Lancet 2002, 359:564-571.
Vosti SA: Malaria among gold miners in southern Para, Brazil:
estimates of determinants and individual costs. Soc Sci Med
1990, 30:1097-1105.
Fazen LE, Anderson RI, Marroquin HF, Arthes FG, Buck AA:
Onchocerciasis in Guatemala. I. Epidemiological studies of
microfilaria. Am J Trop Med Hyg 1975, 24:52-57.
Tanumihardo SA, Permaeish MD: Vitamin A status and hemoglobin concentrations are improved in Indonesian children
with Vitamin A and de-worming interventions. Eur J Clin Nutr
2004, 58:1223-1230.
Zavaleta N, Caufield LE, Garcia T: Changes in iron status during
pregnancy in Peruvian women receiving prenatal iron and
folic acid supplements with or without zinc. Am J Clin Nutr
2000, 71:956-961.
Prasad AS: Zinc deficiency. BMJ 2003, 326:409.
World Bank: Community driven development approaches in
housing sector projects in transition economies. Social Development Notes: Community Driven Development and Urban Services for the
Poor 2004, 71: [http://www.worldbank.org/urban/upgrading/docs/
CDD/cdd-eca-Housing.pdf].
Amazigo UV, Obono M, Dadzie KY, Remme J, Jiya J, Ndyomugyenyi
R, Roungou JB, Noma M, Seketeli A: Monitoring communitydirected treatment programmes for sustainability: lessons
from the African Programme for Onchocerciasis Control
(APOC). Ann Trop Med Parasitol 2002, 96 Suppl 1(Suppl
1):S75-S92.
Pan American Health Organization: Healthy Municipalities and Communities. Mayors' Guide for Promoting Quality of Life Washington, D.C;
2002.
World Health Organization: 4.4.3 Assessments of environmental health hazards (EHH): proposed programme budget
2000-2001.
[http://www.wpro.who.int/NR/rdonlyres/FA0188F6960F-491E-A64E-D9892998A7FD/0/RC5203.pdf].
Pan American Health Organization/World Health Organization:
Planificacion local participativa. In PALTEX Health Promotion
Series Washington DC; 1999.
Ottawa Charter for Health Promotion Adapted from the First
International Conference on Health Promotion: 21 November 1986 [http:/
/www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf].
Health Promotion Project/Department of Health Ministry of Health:
Em Chopinzinho, a melhora qualidade de vida comecou no
campo. Health Promotion Review 1999, 1:27-30.
Pan American Health Organization: An Integrated, Multi-Disease Community Based Approach in the Control of Soil-Transmitted Worms in Brazil
Washington, DC; 2002.
Page 20 of 21
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
Cerqueira MT: Health-Promoting schools. World Health 1996, 4:.

Ippolito-Shepherd J, Cimmino K: La Iniciativa Regional Escuelas Promotoras de la Salud. Ensayos y Experiencias, 45 Salud-Educacin Coleccin
Psicologa y Educacin. Edicin Novedades Educativas; 2002.
Ippolito-Shepherd J: Las Escuelas Promotoras de la Salud en Amrica
Latina Resultados de la Primera Encuesta Regional Volume 3. Serie Promocin de la Salud Washington, DC: OPS/OMS; 2005.
Pan American Health Organization: Health-Promoting Schools: Strengthening of the Regional Initiative. Strategies and Lines of Action 20032012
Volume 4. Health Promotion Series Washington, DC; 2003.
Organizacin Panamericana de la Salud: Memoria de la I Reunin de la
Red Latinoamericana de Escuelas Promotoras de la Salud Washington,
DC: OPS/OMS; 1997.
Organizacin Panamericana de la Salud: Memoria de la IV Reunin de la
Red Latinoamericana de Escuelas Promotoras de la Salud: 11-16 de julio
2004; San Juan, Puerto Rico Volume 11. Serie Promocin de la Salud
Washington, DC: OPS/OMS; 2006.
Organizacin Panamericana de la Salud: Memoria de la III Reunin de la
Red Latinoamericana de Escuelas Promotoras de la Salud: 1013 septiembre 2002; Quito, Ecuador Volume 5. Serie Promocin de la Salud Washington, DC: OPS/OMS; 2003.
Pan American Health Organization: Proceedings of the First Meeting and
Creation of the Caribbean Network of Health-Promoting Schools: 2628
November 2001 Volume 2. Bridgetown, Barbados, Health Promotion
Series Washington, DC: PAHO/WHO; 2002.
World Resources Institute, United Nations Environment Programme,
The United Nations Development Programme, World Bank: World
Resources 199899. A Guide to the Global Environment: Environmental
Change and Human Health New York; 1999.
World Health Organization: Health and the Environment in Sustainable
Development: Five Years After the Earth Summit Geneva; 1997.
Anon: Environmental primary care for the 21st century. Rev
Panam Salud Publica 1998, 4:290-296.
World Bank: World Development Report 1993: Investing in Health
Washington, D.C; 1993.
United Nations: Agenda 21. In Report of the United Nations Conference on Environment and Development: 314 June 1992; Rio de Janeiro
New York; 1992.
Ault SK: Environmental management: a re-emerging vector
control strategy. Am J Trop Med Hyg 1994, 50(6 Suppl):35-49.
Hadi A: A participatory approach to sanitation: experience of
Bangladeshi NGOs. Health Policy Plan 2000, 15:332-337.
Pan American Health Organization: Annual Report of the Director
Washington, D.C; 2000.
World Health Organization: International Workshop, Intensified Control
of Neglected Diseases, Summary Report: 1012 December, 2003; Berlin
[http://whqlibdoc.who.int/hq/2004/
WHO_CDS_CPE_CEE_2004.45.pdf].
Gwatkin DR, Guillot M, Heuveline P: The burden of disease
among the global poor. Lancet 1999, 354:586-589.
Pan American Health Organization: 13th Inter-American Meeting at the
Ministerial Level on Health and Agriculture (RIMSA 13): 2425 April 2003;
Washington,
D.C
[http://www.paho.org/english/ad/dpc/vp/
rimsa13index-e.htm].
Pan American Health Organization: 12th Inter-American Meeting at the
Ministerial Level on Health and Agriculture (RIMSA 12): 24 May 2001;
Sao Paulo, Brazil
[http://bvs.panaftosa.org.br/textoc/rimsa12-fr2001ing.pdf].
World Health Organization: Joint FAO-WHO Expert Committee on Zoonoses third report. World Health Organ Tech Rep Ser
1967, 378:1-127.
Pan American Health Organization: Neglected diseases in
neglected populations with emphasis on zoonoses. 14th InterAmerican Meeting at the Ministerial Level, on Health and Agriculture, Provisional Agenda Item 13.5, RIMSA 14/18: 18 April 2005 .
Carrique-Mas J, Iihoshi N, Widdowson MA, Roca Y, Morales G, Quiroga J, Cejas F, Caihuara M, Ibarra R, Edelsten M: An epidemiological study of Taenia solium cysticercosis in a rural population
in the Bolivian Chaco. Acta Trop 2001, 80:229-235.
Valero MA, Mas-Coma S: Comparative infectivity of Fasciola
hepatica metacercariae from isolates of the main and secondary reservoir animal host species in the Bolivian Altiplano high human endemic region. Folia Parasitol (Praha) 2000,
47:17-22.
Schelling E, Wyss K, Bechir M, Doumagoum M, Zinsstag J: Synergy
between public health and veterinary services to deliver
96.
97.
98.
human and animal health interventions in rural low income

settings. BMJ 2005, 331:1264-1267.
Zinsstag J, Schelling E, Wyss K, Mahamat MB: Potential of cooperation between human and animal health to strengthen
health systems. Lancet 2005, 366:2142-2145.
Moro M: Animal health and primary health care. Educ Med
Salud 1983, 17:263-274.
Rosenswieg F, Perez E, Corvetto J, Tobias S: Improving Sanitation in
Small Towns in Latin America and the Caribbean: Practical Methodology for
Designing a Sustainable Sanitation Plan Washington, DC: US Agency for
International Development; 2002.
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BMC Public Health

Prevention, control, and elimination of neglected diseases in the

Published: 17 January 2007

Received: 31 March 2006

This article is available from: http://www.biomedcentral.com/1471-2458/7/6

BMC Public Health 2007, 7:6

Development thinking and practice have evolved in ways

These threats will continue to rise as poverty is expected to

several other global initiatives have focused exclusively on

Although medically diverse, NDs share features that allow

BMC Public Health 2007, 7:6

Table 1: Poverty statistics among the world's population of 6 billion

port services. This hinders their ability to exercise their

Although NDs are not explicitly mentioned among the

De-worming improves school attendance and thus

BMC Public Health 2007, 7:6

targets for the MDGs. Keeping this objective in mind this

Discussion: the case for a different approach

There exists an urgent need to develop innovative tools to

working multi-disciplinary framework or strategy for

BMC Public Health 2007, 7:6

The combination of these approaches are emerging as an

I. Health of the Indigenous Peoples of the

II. Productive and Healthy Municipalities (PAHO/WHO)

The HIPA Program highlights the importance of four lines

BMC Public Health 2007, 7:6

By incorporating a ND component several areas may be

An investigation of the Pankararu indigenous tribe in the

support from a bi-lateral agency (USAID), developed a

The HIPA Program notes, "There is an urgent need for

BMC Public Health 2007, 7:6

II. Productive and Healthy Municipalities

component of health promotion to ensure access to

For example, recent research on food security and disease

BMC Public Health 2007, 7:6

ing rates by the local principle malaria vector Anopheles

The promotion of household level food production

III. Community Driven Development

BMC Public Health 2007, 7:6

600,000 people, spared 15 million children from living in

IV. Healthy Municipalities and Communities

BMC Public Health 2007, 7:6

1) The formation of a public health policy that goes

HMC strategies encourage the creation of Inter-Sectoral

In the small Canton of San Carlos, Costa Rica the local

BMC Public Health 2007, 7:6

Today children, adolescents, and young people require an

V. Health-Promoting Schools Regional Initiative

A regional survey in 19 Latin American countries [73]

BMC Public Health 2007, 7:6

Health-Promoting Schools strategy. 30% of the countries

cal controls, vaccination and, to a very limited extent,

BMC Public Health 2007, 7:6

The Latin American Network of Health-Promoting

5. Research, evaluation, and surveillance systems for

VI. Primary Environmental Care Strategy

BMC Public Health 2007, 7:6

posal systems, water manipulation in dams and irrigation

Another area in need of inter-sectoral environmental