Urban-rural Region Research Articles

Long-Term Trends in Black and White Mortality in the Rural United States: Evidence of a Race-Specific Rural Mortality Penalty.

The rural mortality penalty-growing disparities in rural-urban macro-level mortality rates-has persisted in the United States since the mid 1980s. Substantial intrarural differences exist: rural places of modest population size, close to urban areas, experience a greater mortality burden than the most rural locales. This research builds on recent findings by examining whether a race-specific rural mortality penalty exists; that is, are some rural areas more detrimental to black and/or white mortality than others? Using data from the Compressed Mortality File from 1968 to 2012, we calculate annual age-adjusted, race-specific mortality rates for all rural-urban regions designated by the Rural-Urban Continuum Codes. Indicators for population, socioeconomic status, and health infrastructure, as a proxy for access to care, are used as predictors of race-specific mortality in multivariable regression models. Three important results emerge from this analysis: (1) there is a substantial mortality disadvantage for both black and white rural Americans, (2) the most advantageous regions of mortality for blacks exhibit higher mortality than the most disadvantageous regions for whites, and (3) access to health care is a much stronger predictor of white mortality than black mortality. The rural mortality penalty is evident in race-specific mortality trends over time, with an added disadvantage in black mortality. The rate of mortality improvement for rural blacks and whites lags behind their same-race, urban counterparts, creating a diverging gap in race-specific mortality trends in rural America.

DEFINING URBAN AND RURAL REGIONS BY MULTIFRACTAL SPECTRUMS OF URBANIZATION

The spatial pattern of the urban–rural regional system is associated with the dynamic process of urbanization. How to characterize the urban–rural terrain using quantitative measurement is a difficult problem remaining to be solved. This paper is devoted to defining urban and rural regions using ideas from fractals. A basic postulate is that human geographical systems are of self-similar patterns correlated with recursive processes. Then multifractal geometry can be employed to describe or define the urban and rural terrain with the level of urbanization. A space-filling index of urban–rural region based on a generalized correlation dimension is presented to reflect the degree of geo-spatial utilization in terms of urbanism. The census data of America and China are used to show how to make empirical analyses of urban–rural multifractals. This work is a normative study rather than a positive study, and it proposes a new way of investigating urban and rural regional systems using fractal theory.

On City-Region Relations. Towards the Urban-Rural Region of Warsaw

Since 1989 Warsaw [Warszawa] has been marked by considerable functional change, accompanied by modernisation of its physical tissue. Yet, there are some factors that can retard Warsaw’s future development. Among them, the most important appears to be the persisting social and economic disparities between the city and its surrounding region. This problem is discerned in strategic spatial policy documents and tends to be addressed in two ways: One of these aims at the generation of spill-over of economic activity towards the peri-urban zone and an enlargement of the city labour market via investment in transportation infrastructure. Another approach is to promote functional polycentricity at the regional level by focusing on the development of the so-called sub-regional centres – several medium-sized cities situated within the radius of ca. 100–120 kilometres from Warsaw, with the goal of strengthening interurban, intra-regional linkages. In this paper some limitations of the above-mentioned approaches are exposed, and an alternative path for the evolution of the city-region relations is outlined, based on the concept of the urban-rural region. This concept emphasises the importance of environmental assets as factors in attracting migrants and economic activities including knowledge- intensive functions to peripherally situated, smaller urban and rural places. In the case of the Region of Warsaw with its extensive, amenity-rich rural countryside, such a development perspective may seem especially relevant. Against this background, in the paper some results are presented and interpreted that are derived from a research project conducted by the author focusing on the development of cultural-cognitive functions in selected small and medium-size towns in the Region.

Evaluating the Effectiveness of First-Time Methadone Maintenance Therapy Across Northern, Rural, and Urban Regions of Ontario, Canada.

Objectives:Our objective was to determine the impact that a patient's geographic status has on the efficacy of first-time methadone maintenance therapy (MMT) retention.Methods:We conducted an observational cohort study using administrative health care databases for patients who commenced methadone therapy between 2003 and 2012. Patients were stratified on the basis of their location of residence into 1 of 4 groups—Southern Urban, Southern Rural, Northern Urban, or Northern Rural. The primary outcome was continuous retention in treatment, defined as 1 year of uninterrupted therapy on the basis of prescription refill data. Mortality was measured as a secondary outcome.Results:We identified 17,211 patients initiating first-time MMT during this 10-year period. Nearly half of patients initiating therapy in northern regions completed 1 year of treatment (48.9%; N = 258 and 47.0%; N = 761 in Northern Rural and Urban regions, respectively), whereas lower rates of 40.6% (N = 410) and 39.3% (N = 5,518) occurred in Southern Rural and Urban regions, respectively. Patients residing in Northern Rural and Northern Urban regions were 31% (adjusted odds ratio = 1.31; 95% confidence interval [CI], 1.09%–1.58%] and 14% (adjusted odds ratio = 1.14; 95% CI, 1.02%–1.27%] more likely to be retained in treatment compared with those residing in Southern Urban regions. There was no significant difference in treatment retention between those residing in Southern Rural and Southern Urban regions. A mortality rate of 3% was observed within 1 year of patients initiating treatment, with patients in the Southern Rural region having the highest rate (4.85%).Conclusions:Our study identified regional differences in retention rates and mortality of first-time MMT. These findings may relate to geographic isolation and limited methadone program availability experienced in northern regions. We interpret the data to suggest that patients who have reduced access to treatment experience higher retention rates when they are able to access therapy.

The Role of Preference on Outcomes of People Receiving Evidence-Informed Community Wound Care in Their Home or in a Nurse-Clinic Setting: A Cohort Study (n = 230).

This study followed a cohort of community-dwelling individuals receiving wound-care in a large urban-rural region. During a randomized control trial (RCT) evaluating outcomes of receiving care in a nurse-clinic or at home, many approached were willing to participate if they could choose their location of care. This provided a unique opportunity to enroll them as a “choice” cohort, following them in the same manner as the trial participants but allowing them to select their setting of care. The objective was to investigate the role of preference and location of care on care outcomes, including satisfaction with care, healing, health-related quality of life (HRQL), pain, and resource use. This is a secondary analysis of a prospective cohort of 126 individuals enrolled in an RCT to receive care at home or in a nurse-clinic (Allocated group), and an additional 104 who received care at home or in a nurse-clinic based on their preference (Choice group). Mobile individuals with a leg ulcer of venous or mixed venous etiology, referred for community leg ulcer care, were eligible. Specially-trained nurses provided care to both groups using an evidence-informed protocol. Baseline data included socio-demographic, circumstance-of-living and a detailed wound assessment. Mean age of the cohort was 68 years. Satisfaction, healing, recurrence, pain, HRQL, and resource utilization did not differ between groups. If available, individuals should have an option of care venue given almost half of those approached indicated a clear preference for clinic or home. With outcomes being similar, health care planners and decision-makers, as well as individuals and their families, can feel confident that the setting of care will not impact the outcomes. However, larger studies in other contexts are needed to explore the interaction between choice and setting.

Warsaw urban-rural region - an alternative development perspective?

In this article questions are posed concerning the spatial structure of the Warsaw region and its development trends. These are presented against recent conceptual approaches to the study of metropolitan regions. Alternative hypotheses are discussed related to continuing spatial polarization, the emergence of polycentric urban patterns, as well as growing functional interdependence between the urban and the predominantly rural areas within the region. This is placed in the context of public policy objectives concerning both territorial cohesion and socio-economic growth; the latter hidden under the region’s competitiveness label. Empirical findings from a comparative analysis of the location behavior of selected firms in the advanced services sector are referred to in the discussion. It is argued that in projecting the region’s development path into the future, the concept of the urban-rural region is of particular relevance. Such an approach may also be adopted for use in developing spatial policy.

Changing rural development inequality in Jilin Province, Northeast China

Rural development inequality is an important practical issue during the course of full establishment of a ‘moderately well-off society’ in modern China, and the objective understanding and evaluation of the status and regional inequality of rural development can provide scientific basis for ‘building a new countryside’ and coordination development of rural-urban regions. Based on the county-level data of 2000, 2005 and 2009, this paper examines the rural development inequality of Jilin Province in Northeast China by establishing a rural development index. The spatio-temporal dynamic patterns and domain factors are discussed by using the method of exploratory spatial data analysis and multi-regression model. The results are shown as follows. Firstly, most of the counties were in lower development level, which accounted for 58.3%, 62.5% and 66.7% of the total counties in 2000, 2005 and 2009, respectively. The characteristics of spatial inequality were very obvious at county level. For example, rural development level of Changchun Proper and the proper of seven prefecture-level cities were much higher than that of the surrounding regions. The counties in the eastern and northern Jilin Province were the lowest regions of rural development level, while the middle counties were the rapid growth areas in rural economy. Secondly, Moran’s I of rural development index (RDI) was 0.01, −0.16 and −0.06 in 2000, 2005 and 2009, respectively, which indicated that spatial agglomeration of RDI was not obvious in Jilin Province, and took on the characteristic of random distribution. The counties of both the units and its adjacent units have higher development level (HH) were transferred from the western areas to the eastern areas, while the countries of both the units and its adjacent units have lower development level (LL) were diffused from the eastern to middle and western Jilin Province. Finally, the result of multi-regression analysis showed that the improvement of agricultural production condition, development of agricultural economics and the adjustment of industrial structure were the domain factors affecting rural development inequality of Jilin Province in the later ten years.

Body mass index for children aged 6–18 years in Beijing, China

Background: Obesity constitutes one of the most important worldwide public health concerns.Aim: To develop BMI percentile curves by age, sex and urban–rural regions for Beijing children and compare the results with Chinese national data and international references.Subjects and methods: Boys (4078) and girls (4077), aged 6–18 years, were recruited from 1 September to 30 November 2005 in Beijing, China. BMI percentile curves were constructed using the LMS method.Results: BMI curves differed between boys and girls. BMI curves for urban children were higher than rural children at the upper percentile. Beijing BMI curves were higher than the Chinese national level. Beijing boys had a higher BMI in medium (6.5–14 years) and upper percentiles and a lower BMI in lower percentiles than WHO and developed references, whereas Beijing girls were lower in medium and lower percentiles, but higher compared to a WHO reference before age 15.5 years in upper percentiles.Conclusions: Beijing children are fatter than the Chinese national level. Beijing urban children are fatter than rural Beijing children. The polarization of BMI values for Beijing boys suggests these children face a dual-burden of nutrition. Effective policies and interventions to control obesity and underweight in Chinese children are necessary.

Agriculture Under Human Influence: A Spatial Analysis of Farming Systems and Land Use in European Rural-Urban-Regions

Abstract: Peri-urban agriculture in metropolitan regions is exposed to severe urbanisation pressures related to land and labour availability, thus limiting farming activities. Nevertheless, peri-urban agriculture reveals specific characteristics that contribute to the local food supply and the management of a multifunctional countryside near towns. This paper seeks to investigate agricultural land-use and farming-system characteristics in peri-urban areas within Rural-Urban Regions (RUR) across the EU27. The RUR model, which includes an allocation of urban, peri-urban and rural areas, is developed and applied in spatial and statistical analyses to identify relationships between urbanisation and agriculture. The results indicate that metropolitan agriculture compensates shrinking land bases by increasing the intensity of the labour and turnover generated, and is furthermore specialised at developing horticultural produce that is oriented towards urban consumer markets. Keywords: Peri-urban, horticulture, competiveness, specialisation, urban-rural relationships, metropolitan regions, land consumption

Place branding by building coalitions; lessons from rural–urban regions in the Netherlands

This article aims to contribute to the conceptual and empirical understanding of branding strategies in rural–urban areas. We argue here that branding at the regional level ideally can be seen as the interaction of three intertwined processes: identification of territorial capital, the re-grounding of practices and products in place-based characteristics, and a multi-stakeholder process to develop an inner storyline (brand). We focus in this article on regional collaboration in multi-stakeholder processes, paying special attention to initiating forms of public–private self-organization (so called ‘vital coalitions’). As a theoretical framework, we use theoretical notions of Urban Regime Theory. We will investigate under which conditions vital coalitions can contribute to place branding strategies. We illustrate this by describing two empirical rural–urban cases in the Netherlands where a branding strategy has been implemented based on territorial capital.

Neglected Tropical Diseases of the Middle East and North Africa: Review of Their Prevalence, Distribution, and Opportunities for Control

The neglected tropical diseases (NTDs) are highly endemic but patchily distributed among the 20 countries and almost 400 million people of the Middle East and North Africa (MENA) region, and disproportionately affect an estimated 65 million people living on less than US$2 per day. Egypt has the largest number of people living in poverty of any MENA nation, while Yemen has the highest prevalence of people living in poverty. These two nations stand out for having suffered the highest rates of many NTDs, including the soil-transmitted nematode infections, filarial infections, schistosomiasis, fascioliasis, leprosy, and trachoma, although they should be recognized for recent measures aimed at NTD control. Leishmaniasis, especially cutaneous leishmaniasis, is endemic in Syria, Iran, Iraq, Libya, Morocco, and elsewhere in the region. Both zoonotic (Leishmania major) and anthroponotic (Leishmania tropica) forms are endemic in MENA in rural arid regions and urban regions, respectively. Other endemic zoonotic NTDs include cystic echinococcosis, fascioliasis, and brucellosis. Dengue is endemic in Saudi Arabia, where Rift Valley fever and Alkhurma hemorrhagic fever have also emerged. Great strides have been made towards elimination of several endemic NTDs, including lymphatic filariasis in Egypt and Yemen; schistosomiasis in Iran, Morocco, and Oman; and trachoma in Morocco, Algeria, Iran, Libya, Oman, Saudi Arabia, Tunisia, and the United Arab Emirates. A particularly noteworthy achievement is the long battle waged against schistosomiasis in Egypt, where prevalence has been brought down by regular praziquantel treatment. Conflict and human and animal migrations are key social determinants in preventing the control or elimination of NTDs in the MENA, while local political will, strengthened international and intersectoral cooperative efforts for surveillance, mass drug administration, and vaccination are essential for elimination.

Quality of Life and Ecosystem Services in Rural-Urban Regions

The study here presented concerns the possibility of making use of the natural environmental potential, expressed through ecosystem services, in the establishment of foundations for and the direction of development of the rural-urban areas. The purpose of the study is to show the potentialities of using ecosystem services in governance, directed towards the economic and social development of the rural-urban regions, with consideration of improvement in quality of human life and preservation of the most valuable resources of nature as well as landscape qualities. Ecosystem services, being the nature-provided good, play an increasingly important role in the shaping of social and economic policies within the peri-urban areas, and thereby also their direct influence on the standard of living of the inhabitants increases. The scope of analysis that is presented in the report encompasses the problems of using the potential of the environment in the development of regions on the basis of modelling of reality with due account of the level of social awareness in the context of pro-ecological behaviour patterns. Assumption was adopted that even small differences in the initial parameters or a disturbance of the trajectory of regional development may have an essential impact on the ultimate effect, that is - on the role played by ecosystem services in this process.

Malnutrition in school children in an urban-rural region of the extreme South of São Paulo city.

To evaluate the persistence of nutritional deficit in a sample of schoolchildren. A cross-sectional study of 1,761 schoolchildren between 6 and 10 years from 3 schools. They were assessed by Z scores of weight for height and height for age, according to the World Health Organization. The variables studied were gender, age, grade and school year. The χ² test was used to relate the nutritional deficit with the variables. Of all children 8.5% were malnourished according to the weight for height Z score, 21.6%, according to height for age. The analysis of the weight for height Z score revealed that 59.7% were male and 40.3% female. The mean age was 8.9 years. As to the Z score of height for age, 53.9% were males and 46.1% females. The risk of malnutrition was higher among boys: 59.7% for the weight for height index and 53.9% for height for age. There was no statistical difference between schools, gender and school year. As to nutritional status, school period (p < 0.0001) and students' grade (p = 0.0105), we observed statistical significance. Malnutrition still persists among the low-income population and males had a higher percentage of malnutrition. Nutritional evaluation of students is an extremely important tool for understanding the dynamics of child nutrition and development.

Design matters in secondary prevention: individualization and supervised exercise improves the effectiveness of cardiac rehabilitation

Hospital or centre-based cardiac rehabilitation (CR) can lengthen and improve life. However, most existing trials do not examine the effects of design characteristics. To examine the effects of these characteristics, this study compared an individualized cardiac rehabilitation programme to a standardized programme and examined what factors contributed most to programme effects. A prospective cohort analysis was done comparing patients using an individualized centre-based cardiac rehabilitation programme (ICR) in a mixed urban-rural region of the west of Scotland, to a standardized cardiac rehabilitation programme (SCR) provided at the same site three years previously. Both inter- and intra-programme differences in outcomes were explored. More patients were referred to ICR than SCR (749 versus 414 patients, p = 0.002) and the proportion of patients who subsequently attended was around 30% higher (p < 0.0001) although the overall rate of referral to ICR was lower (70% versus 62%, p = 0.002). ICR was associated with a reduction in hospital admission compared to SCR (HR: 0.664: 95% confidence interval (CI) 0.554 to 0.797). ICR patients also had significantly shorter hospitalizations (mean: 8.02 days versus 5.84 days, p < 0.05). ICR patients who attended at least 75% of the exercise sessions were significantly less likely to be hospitalized than individuals who partially attended (HR 2.39, 95% CI: 1.659 to 3.488) or did not participate in exercise sessions (HR 2.16, 95% CI: 1.482 to 3.143). Individualized content and supervised exercise components are key design characteristics for improving outcomes from centre-based CR in clinically representative populations.

1427 Persistence of Malnutrition in School Children in Urban-Rural Region of the South of SãO Paulo City

Objective: To examine in a sample of students from a region of low socioeconomic status, the persistence of nutritional deficit. Method: Cross-sectional study of 1761 schoolchildren between 6 and 10 years from three schools in Parelheiros. Were assessed by z scores of weight for age and height for age, according to World Health Organization The variables studied were: gender, age, grade and school year. We used the chi-square to relate the nutritional deficit with the variables. Results: Of 1761 children studied 8.5% were malnourished according to z score P / E, 21.6%, according to E / I. The analysis of z score P / E revealed that 58.4% were male and 66.7% female. The mean age was 8.9 years. The z score of E / I 53.4% were male and 56.5% female. The risk of malnutrition was higher among boys: 59.7% for the index P / E and 53.9% for E / I. There was no statistically significant difference between the schools, gender and school year. Among nutritional status, period (P < 0.0001) and students grade (p = 0.0105), we observed statistical significance. Conclusion: Malnutrition is still continuing between the low-income population and males had a higher percentage of malnutrition. From the analysis in the region, one can consider that the nutritional assessment of school - the anthropometric technique in particular - is an extremely important tool for understanding the dynamics of child nutrition and development.

Occurrence of Polybrominated Diphenyl Ethers in Air and Precipitation of the Pearl River Delta, South China: Annual Washout Ratios and Depositional Rates

On the basis of a one-year (from October 2006 to September 2007) sampling campaign, 34 air samples and 23 bulk precipitation samples were collected in the Pearl River Delta (PRD) in southern China and analyzed for polybrominated diphenyl ethers (PBDEs). Fifteen tri- to deca-BDE congeners (sum of which is defined as Sigma15PBDE) were detected in more than 70% of the samples. In three urban-rural regions, Sigma15PBDE concentrations ranged from 77 to 372 pg/m3 in air (particulate + vapor) and 1.98 to 15.5 ng/L in rain (particle+dissolved) from Dongguan, from 195 to 1450 pg/m3 in air and 4.71 to 17.2 ng/L in rain from Shunde, and from 23.7 to 148 ng/L in rain from Guangzhou. Among the BDE congeners, BDE-209 was the predominant component. Linear correlations between the gas-particle partition coefficients (Kp) and the subcooled vapor pressures (P(O/L)) of individual BDE congeners were observed for both the wet and dry seasons, but the slopes (-0.572 to -0.525) of the fitted equations all substantially deviated from equilibrium condition (slope = -1). The total washout ratio by bulk rainfalls was determined to be 2 x 103 for tri-BDEs and 6 x 104 for BDE-209. The estimated annual dry and wet depositional rates were 6720 and 2460 kg/yr, respectively, for BDE-209, and 7270 and 2940 kg/yr for Sigma15PBDE in the PRD, indicating a dominant pathway for PBDEs input into the PRD soil and aquatic environments.

Psychotropic medication use among nursing home residents in Austria: a cross-sectional study

BackgroundThe use of psychotropic medications and their adverse effects in frail elderly has been debated extensively. However, recent data from European studies show that these drugs are still frequently prescribed in nursing home residents. In Austria, prevalence data are lacking. We aimed to determine the prevalence of psychotropic medication prescription in Austrian nursing homes and to explore characteristics associated with their prescription.MethodsCross-sectional study and association analysis in forty-eight out of 50 nursing homes with 1844 out of a total of 2005 residents in a defined urban-rural region in Austria. Prescribed medication was retrieved from residents' charts. Psychotropic medications were coded according to the Anatomical Therapeutic Chemical Classification 2005. Cluster-adjusted multiple logistic regression analysis was performed to investigate institutional and residents' characteristics associated with prescription.ResultsResidents' mean age was 81; 73% of residents were female. Mean cluster-adjusted prevalence of residents with at least one psychotropic medication was 74.6% (95% confidence interval, CI, 72.0–77.2). A total of 45.9% (95% CI 42.7–49.1) had at least one prescription of an antipsychotic medication. Two third of all antipsychotic medications were prescribed for bedtime use only. Anxiolytics were prescribed in 22.2% (95% CI 20.0–24.5), hypnotics in 13.3% (95% CI 11.3–15.4), and antidepressants in 36.8% (95% CI 34.1–39.6) of residents. None of the institutional characteristics and only few residents' characteristics were significantly associated with psychotropic medication prescription. Permanent restlessness was positively associated with psychotropic medication prescription (AOR 1.54, 95% CI 1.32–1.79) whereas cognitive impairment was inversely associated (AOR 0.70, 95% CI 0.56–0.88).ConclusionFrequency of psychotropic medication prescription is high in Austrian nursing homes compared to recent published data from other countries. Interventions should aim at reduction and optimisation of prescriptions.

Understanding the Supportive Care Needs of Parents of Children With Cancer: An Approach to Local Needs Assessment

The objective of this study was to conduct an assessment of supportive care needs from the perspective of parents of children diagnosed with cancer within an urban-rural region in Eastern Ontario, Canada. Guided by a conceptual framework for supportive care, the exploratory, mixed-method study used a standard needs survey and semistructured interviews. Fifteen parents completed (75% response rate) the survey, and 3 parents participated as key informants in the follow-up interview. Parents reported needs in all 6 of the need categories outlined within the Supportive Care Needs Framework. The proportion of parents expressing a need ranged from 23% to 39%. Dealing with the fear of their child's cancer spreading was frequently identified by parents. Emotional and informational needs were the 2 most frequently acknowledged categories of need. With further refinement, the use of the conceptual framework will provide a methodology for planning care based on the individual needs identified by parents of children with cancer.

The seroprevalence of diphtheria among adults in Izmir-Turkey

A serological survey to determine the immunity to diphtheria in the adult population in Izmir-Turkey was conducted according to the recommendations of the World Health Organization. A total of 339 blood samples were collected from subjects aged between 20 and 81, and diphtheria antitoxin levels were measured by the enzyme linked immunosorbent assay method. Titers below 0.1 IU/ml were considered to show insufficient immunity. Of the studied population, 56.3% had showed insufficient immunity against diphtheria. Diphtheria protection rates showed a gradual age-related decrease. The lowest immunity rate was observed in 40–49-year age group (30.6%) ( p < 0.05). There was no significant difference in the rate of immunity between subjects in terms of sex, levels of education, urban–rural region ( p > 0.05). These results emphasize the need for booster immunization of adults. The present vaccination policy should include re-vaccinations of the adult population every 10 years in order to provide a complete protection of the population.

Fighting Tropical Diseases

![Figure][1] Jeffrey D. Sachs ![Figure][1] Peter J. Hotez The global fight against extreme poverty requires a solid partnership between physical scientists, social scientists, civil society, and policy-makers. For too long, extreme poverty has been viewed mainly or exclusively through the lens of economics and politics. Yet the root causes of extreme poverty involve science-based challenges requiring expertise in disciplines including disease ecology, medicine, public health, climatology, agronomy, and soil science. A new effort to control several of the major killer infectious diseases in Africa ([www.earth.columbia.edu/malaria-ntd][2]) illustrates the promise of a science-based policy approach to the fight against poverty, hunger, and disease. The United Nations (UN) Millennium Development Goals—the world's shared objectives for fighting extreme poverty—put a major focus on AIDS, tuberculosis, malaria, and “other diseases” not explicitly mentioned. These include several neglected tropical diseases that impose a combined disease burden rivaling that of the “big three”: AIDS, tuberculosis, and malaria. These neglected tropical diseases share a high prevalence in rural and poor urban regions of low-income countries, an ability to promote poverty, and disabling and stigmatizing characteristics. Moreover, efforts to control these diseases have been underappreciated, achieving successes not widely known in the policy community. A policy effort initiated this year by the UN Millennium Project and the Earth Institute at Columbia University will link a scaling-up of the fight against malaria with expanded efforts against several parasitic and bacterial infections, including leishmaniasis, trypanosomiasis, hookworm, lymphatic filariasis, onchocerciasis, schistosomiasis, leprosy, Buruli ulcer, and trachoma. At a January 2006 meeting at the Karolinska Institute in Stockholm, specialists in malaria control, the neglected tropical diseases, and economic development compared evidence and planned a joint campaign for comprehensive disease control. The initial effort will focus on 10 countries (Ethiopia, Ghana, Kenya, Malawi, Mali, Nigeria, Rwanda, Senegal, Tanzania, and Uganda) that have pledged to have comprehensive scale-up plans to fight malaria as well as the neglected tropical diseases ready by the end of April 2006 and to seek funding from the Global Fund to Fight AIDS, Tuberculosis, and Malaria; the World Bank; and other sources. There are several motivations for this new effort. First, recent analyses indicate that the disease burden imposed by neglected tropical diseases has been underestimated; they not only cause approximately 530,000 deaths annually but also cause much more long-term disability, disfigurement, and suffering. These diseases rival AIDS, tuberculosis, and malaria, resulting in a loss of up to 57 million disability-adjusted life years annually. Epidemiologic studies suggest extensive geographic overlap among these diseases and with AIDS, tuberculosis, and malaria, resulting in polyparasitism, especially among the poor. Second, chronic parasitic infections may increase an individual's risk of acquiring a “big three” disease or worsen its progression. These observations strengthen the rationale for incorporating treatments for parasitic diseases into control programs for the big three. ![Figure][1] CREDIT: REUTERS/GRANT LEE NEUENBURG It is possible to design an easy-to-use “rapid-impact” package for simultaneously treating seven neglected tropical diseases— ascariasis, hookworm, trichuriasis, lymphatic filariasis, onchocerciasis, schistosomiasis, and trachoma—for less than $1 per person per year plus free donations of four of the five impact-package drugs (azithromycin, albendazole, ivermectin, and mebendazole) by Pfizer, GSK, Merck, and Johnson & Johnson, respectively. In addition, praziquantel is available from various generic manufacturers at low cost. Scaling the rapid-impact package for all of Africa would require an estimated $200 million per year in addition to approximately $3 billion per year for malaria control. By integrating the control of neglected tropical diseases with malaria control, this pro-poor package could reduce the disease burden by as much as would the control of any of the big three diseases. This scale-up will require novel and careful coordination between national program managers for malaria and their counterparts who deal with neglected tropical diseases, with attention to the complexities of compliance, drug interactions, drug resistance, monitoring, and sustainability. However, if successful, a coordinated assault on these tropical infections could become one of the best buys in all of public health. This integration should be incorporated into the next round of funding proposals for the Global Fund to Fight AIDS, Tuberculosis, and Malaria and be considered by other global health initiatives. [1]: pending:yes [2]: http://www.earth.columbia.edu/malaria-ntd