Cover: Forgotten People, Forgotten Diseases, 3 Edition by Peter J. Hotez

Forgotten People, Forgotten Diseases

The Neglected Tropical Diseases and Their Impact on Global Health and Development

Third Edition


Professor of Pediatrics and Molecular Virology & Microbiology Texas Children's Hospital Chair of Tropical Pediatrics National School of Tropical Medicine, Baylor College of Medicine Houston, Texas











Logo: Wiley

Dedicated to my wife, Ann Hotez, and my four adult kids, Matthew Hotez, Emily Hotez, Rachel Hotez, and Daniel Hotez

To my mother, Jean Hotez, and brother and sister, Lawrence Hotes, M.D., and Elizabeth Kirshenbaum, J.D., and their families

To the memory of my brother and father, Richard Hotes, M.D. Edward Joseph Hotez

To Mark Wallace and Paul Klotman, M.D., and the leadership of Texas Children's Hospital and Baylor College of Medicine

And to the Bill & Melinda Gates Foundation, the U.S. National Institutes of Health, and the Kleberg Foundation for the opportunity to devote my life to the Neglected Tropical Diseases


Ever since junior high school, I have been fascinated by the application of scientific knowledge for solving tropical public health problems of global importance. Starting with an M.D.‐Ph.D. dissertation begun in 1980, my adult life has been a quest to develop experimental vaccines for diseases of the poor, beginning with human hookworm infection. More than 20 years ago, thanks to the support of the Bill & Melinda Gates Foundation, I had the opportunity and good fortune to head a multidisciplinary team to develop and manufacture those vaccines and test them in areas of Brazil and Gabon and where hookworm was endemic. Since then our group, now co‐headed by my science partner for the last 20 years, Dr. Maria Elena Bottazzi, has led the development of vaccines against schistosomiasis, Chagas disease, and other neglected tropical diseases (NTDs). Starting in 2011 we began using this same approach to develop coronavirus vaccines, including vaccines against SARS and MERS, and beginning in 2020 we turned our attention to COVID‐19. As a result a new low‐cost recombinant protein, COVID‐19 vaccine is being scaled up for production in India, with the hope that it will fill a troubling gap in terms of COVID‐19 vaccines for Africa and Latin America. While that work was intensely satisfying on both a professional and personal level, I realized that completing early‐stage development of a new product for an NTD such as hookworm was in many ways the easy part! It was apparent that unless there was greater general awareness about the public health and economic importance of NTDs there would never be the political will and large‐scale financial investment necessary to ensure global access to a hookworm vaccine, or indeed any other product for the diseases of poverty.

The first edition of Forgotten People, Forgotten Diseases focused on summarizing in mostly nontechnical language the major concepts about NTDs and how they cause human suffering, as well as their global importance and the unique and unusual opportunity we had to lift the world's poorest people out of poverty through low‐cost and highly cost‐effective control measures. Along with Professor David H. Molyneux of the Liverpool School of Tropical Medicine, Professor Alan Fenwick from Imperial College London, Dr. Lorenzo Savioli from the World Health Organization (as well as some of his close colleagues there, including Drs. Dirk Engels and Jacob Kumaresan), Professor Jeffrey Sachs and Dr. Sonia Ehrlich Sachs of Columbia's Earth Institute, and Dr. Eric Ottesen (then at Emory University), I formed an informal NTD working group, and in a series of policy papers published in PLoS and the New England Journal of Medicine, we were able to articulate the concept of the NTDs and how we could control or eliminate them through a global scale‐up of access to essential medicines. We also established a Global Network for NTDs to coordinate global advocacy and resource mobilization efforts for these conditions.

By the time of the second edition, published in 2013, much had already begun to change. In the area of public health control in developing countries, and through support from the United States Agency for International Development (USAID), approximately 250 million people had been treated with all or part of an integrated “rapid‐impact package” of essential medicines for seven of the most common NTDs—ascariasis, hookworm infection, trichuriasis, schistosomiasis, lymphatic filariasis, onchocerciasis, and trachoma. The World Health Organization estimated that more than 700 million people annually were receiving essential medicines against one or more NTDs—almost all of whom were living in the poorest parts of Africa, Asia, and the Americas—representing some of the largest public health control efforts ever undertaken. The successes of both mass drug administration and product development activities rely heavily on a substantial alliance of private‐public partnerships, including product development partnerships and nongovernmental development organizations, as well as international advocacy efforts to raise awareness about the NTDs (including the Global Network for Neglected Tropical Diseases) and parallel resource mobilization initiatives. Another major development was the realization that NTDs also occur among the poor living in wealthy countries, especially the United States and, to some extent, Europe. In 2011, I committed my life and work to this problem by relocating a group of more than a dozen scientists to Texas in order to establish the Texas Children's Hospital Center for Vaccine Development and the new National School of Tropical Medicine at Baylor College of Medicine. Through the hard work of our faculty and scientists, we uncovered an extraordinary disease burden from NTDs in Texas and adjacent Gulf Coast states, including Chagas disease, dengue, Zika virus infection, murine typhus, toxocariasis, trichomoniasis, and hookworm infection. NTDs and poverty are inextricably linked.

This third edition of Forgotten People, Forgotten Diseases coincides with the third decade of the NTDs movement and ecosystem that began in the early 2000s. Now mass drug administration/preventive chemotherapy is taken for granted as a recognized international standard for advancing global health and for addressing the plight of people who live in profound poverty. But this approach truly represents hard‐fought efforts from our small group of tropical and parasitic disease experts, who included my “three musketeer” colleagues Alan Fenwick and David Molyneux, as well as the leaders of the WHO's Department of NTDs Control—Lorenzo Savioli, Dirk Engels, Mwele Ntuli Malecela, and so many others.

Today, more than 1 billion people benefit from access to essential NTD medicines, and also the many collateral benefits in terms of therapeutic effects on diseases that we did not necessarily intend to target. This book tells the story of how the NTD space evolved and control was implemented on a global scale. It discusses some of the major non‐governmental development organizations committed to NTDs and advocacy for the NTDs, and the important contributions of the U.S. and U.K. governments, as well as the Bill & Melinda Gates Foundation, as well as other organizations. It tells how we measured the health and economic impact of the NTDs through the Global Burden of Disease (GBD) Study of the Institute for Health Metrics and Evaluation at the University of Washington. It also highlights the role of innovation in the development of new treatments and vaccines for NTDs, and the role of important product development partnerships, including ours, and others such as DNDi, IDRI, IVI, and FIND, to name some. It explains how science and vaccine diplomacy ensures that a new generation of these biotechnologies reaches the world's poorest people. Most of all, it tells the story of the world's people who live in extreme poverty and what it means for them to live with NTDs.


Houston, Texas


This book and my career in tropical medicine owe so much, to so many people. I had the unique opportunity to thank many of them during my 2011 Presidential Address to the American Society of Tropical Medicine and Hygiene.1 I again want to thank my bosses at Baylor College of Medicine and Texas Children's Hospital, Dr. Paul Klotman and Mark Wallace, respectively, and the boards of those two institutions. I also thank my long‐standing colleagues and partners in battle against the neglected tropical diseases (NTDs), including Professors David Molyneux and Alan Fenwick; and Drs. Lorenzo Savioli, Dirk Engels, and Mwele Ntuli Malecela—past and current heads of the Department of Control of NTDs of the WHO. Also thanks to TDR, the Special Programme for Research and Training in Tropical Diseases, of the World Health Organization. I also thank my science partner for the last 20 years, Dr. Maria Elena Bottazzi, and our team of amazing scientists at the Texas Children's Center for Vaccine Development, and the heads and directors of the many organizations committed to NTDs, which include the areas of implementation, product development, and advocacy. Along those lines I want to thank the heads of the important non‐governmental development organizations, public‐private partnerships, and product development partnerships committed to the NTDs, and my good colleagues at PLoS Neglected Tropical Diseases. A special thank you to Drs. Patrick Soon‐Shiong and Gary Michelson for their commitment and interest in NTDs. I also extend my appreciation to the work of the Institute for Health Metrics and Evaluation of the University of Washington for its Global Burden of Disease Study (GBD) 2019. This book presents the results and mapping from the GBD 2019 for each of the major NTDs. I also want to thank Alyssa Milano for her long‐standing commitment to NTDs and both Alyssa and Soledad O'Brien for their willingness to contribute forewords for the previous two editions. Many thanks to Nathaniel Wolf for his editorial assistance and insights and to Ashish Damania for his help with new maps and other related materials. I also thank Douglas Soriano Osejo for his help. Finally, many thanks to the donors and partners that made it possible for me to pursue a career in NTDs, including the Bill & Melinda Gates Foundation, the U.S. National Institutes of Health (especially the National Institute of Allergy and Infectious Diseases and the Fogarty International Center), the Robert J. Kleberg, Jr. and Helen C. Kleberg Foundation, the Carlos Slim Foundation, JPB Foundation, Tito's Vodka, Southwest Electronic Energy Medical Research Institute, Blavatnik Charitable Trust, Rebecca Marvil and Brian Smyth, Mendell Family Fund, MD Anderson Foundation, Rawley Foundation, John S. Dunn Foundation, Jay H. Newman and Newman Family Foundation, Jerold B. Katz Foundation, Jesse W. Couch Charitable Foundation, and others. Finally, I want to thank my wife Ann Hotez and my family for bearing with me through another edition of Forgotten People, Forgotten Diseases, and Christine Charlip for “rolling the dice” once again with me at ASM Press.


Houston, Texas


  1. 1.Hotez PJ. 2012. ASTMH Presidential Address. Four Horsemen of the Apocalypse. Am J Trop Med Hyg 87: 3–10.