Poverty and Disease

The problems of health that are problems for all societies. In the rich world where health conditions are far better than in the poor countries. The problems of very high and rising costs of health care are front and center on the political and the economic agenda. In the poorest countries the challenges of course are also about finances but much more importantly about the tragic loses of life and the very high burdens of disease. Often from conditions that have been eliminated completely in the high income world.

Poverty and ill health go together and we need to understand that linkage of poverty and ill health because understanding it enables us not only to. Address the challenges of heavy diseased burdens of pour countries but also gives us an added and important tool for breaking the poverty trap itself. We should expect two-way causation, that poverty Contributes to disease in many, many ways, but disease of course also contributes to poverty. An individual suffering from disease loses income. A community or country with a heavy disease burden similarly loses income from. Sickness in the population, lack of productivity, other burdens that arise in the economy when there is a large amount of unattended disease. How does disease contribute to poverty? Think about the, the following pathways. First through the adverse life cycle development of a, of an individual. If a young child survives illness but is buffeted by repeated illnesses when you. We now understand better that not only is that likely to set the child back in terns of readiness for school perhaps in terms of school enrollment or primary school completion. But that early bout of illness can have a lifetime effect on cognitive and physical development and on vulnerability even.

At adult ages to various kinds of diseases unexpected diseases. Cardiovascular disease can be affected by nutrition that is poor in early age. So human development across the life cycle. Is strongly affected by health and disease. Disease can have long term individual consequences. Disease burdens of adults in the labor force of course can have large and adverse results for an economy. Think about a village that has to harvest the crop. The crop may be the absolute lifeline for the village to enable it to eat throughout the coming year. But in many places, just at harvest time, there’s also the risk of a malaria epidemic. Malaria is a disease that is transmitted by the bite of a mosquito. The mosquitoes are breeding during the rainy season, the same time that the crops are growing. By the time it’s right to harvest the crops, it may be that the larvae have developed into mosquitoes now transmitting malaria infection. It’s not uncommon, therefore, that just when harvest time comes, the whole community is knocked out by malaria and can’t harvest the crops. Think of the consequences of that for poverty for devastation, for hunger, even for famine in the coming year. Of course, another economic consequence of ill health is the direct cost of health care itself, if a community can afford the health care. That eats up a budget, and it can be very, very expensive treating the diseases for very poor people. Even what would seem to be, modest outlays of a few dollars or a few tens of dollars, for a disease. Amounts that would hardly be noticed in the rich world can be the margin of survival for poor families that hardly have enough to eat to start with and may lose their last remaining monetary income to the effects of a disease.

A disease burden contributes indirectly and over the long term to demographic problems. Remember how high total fertility rates can impede economic development, when the population’s growing rapidly, and when the community is supporting a lot of young children, and looking after them. And having to put them through school, and build new schools for a growing youth population. Who are not themselves earning income at the time, the burden of rapid population growth and a very young age distribution, I, is a huge hindrance for economic development. We’ve noted already on several occasions that a rapid voluntary reduction of fertility can be a big boost as it was in China to economic growth. But consider what happens when there’s a heavy disease burden. When out of every 1000 children born, 100 or 200 or 300 don’t survive to adulthood. Parents knowing of the high risks of children’s deaths. Therefore respond by having large numbers of children and if the household wants to be absolutely sure that there is a surviving son. For instance, for cultural reasons to perform the funeral rights or for very pragmatic economic reasons to support the mother and the father in their old age. Families may choose to have two or three or four sons to make sure that at least one survives but having two or three or four sons might mean having four or six or eight children as a whole. And so this is another indirect way often overlooked at how high disease burden is conducive to a perpetuation of poverty. Finally, one should note, investors are not so keen on investing into a high malaria zone or into a high AIDS region. Think of it that you are aware that your labor force could be very sick, could be dying young. A need to replace many, many workers as a hotel manager you’re aware that you’re trying to get guests to your hotel but after every rainy season there’s a malaria epidemic. It doesn’t seem very attractive for investment. You’re a mine manager. But you’re surrounded by infectious diseases like malaria. Well, foreign investors don’t like to head to those locations. This is yet another way how disease leads to poverty. But the arrow goes the other way as well. And I think that’s the direction that people perhaps most naturally consider how poverty contributes to disease.The answer that  trips off the tongue and comes to mind is can’t afford a doctor. And of course poverty does mean a much lower access or no access at all to medicine to modern doctors to basic health services, but there are many, many other ways that poverty contributes to a heavy disease burden.

One that I’ve mentioned already is the immuno-suppression that comes from chronic under-nutrition. Children who are not fed well, who lack basic micronutrients, have immune systems that are tuned down, that are not as effective, not as able to resist disease. Poverty also tends to mean a more dangerous physical environment. Poor families in rural areas typically don’t have reliable sources of safe drinking water or reliable clean sanitation. There’s open defecation it means that many diseases cycle through the body and are spread by open deification and the pathogen getting back into the ground water. And back into the wells and back into the water supply a diseases like cholera are spread in this manner. And so poor communities have poor infrastructure lack of access to the basic environmental conditions for good health. Poor people live in adobe huts with thatch roofs, often with a gap between the thatch and the walls a gap in which various insects can easily enter, mosquitoes bearing malaria or flies bearing other diseases or other insects that are coming and spreading disease. So even the physical structure of the housing can make a very, very big difference. Poverty is related to the ecological conditions of disease. Worm infections like hookworm or Trichuris or Ascaris are in warm, wet, tropical climates. Poor people living in the warm, wet tropics are subject to a much heavier helminth or worm infection. That’s part of the reason for their poverty, but it’s also the cause of poverty coming from the disease burden. Malaria is a disease of the hot tropics and, as a result the poor people living in that region have this extra burden of disease. One can say that it’s a condition of poverty, it’s really a condition of the geography associated with poverty. Poverty is also associated often with illiteracy, innumeracy the lack of ability of individuals to seek health in the right way or to understand what to do or how to fill a prescription or how to adhere to a drug regimen if that’s what’s needed. And so, health seeking behavior is extremely important for all of us. Poor people have a harder time with less education and less ability to fair out the right kinds of help. That’s why workers like community health workers can be so important to help poor people make the connections with the health system itself. And people living in poverty are very, very vulnerable to doing dirty and dangerous work. Young women who because of their extraordinary vulnerability, end up in sex trades, for example. And vulnerable to AIDS and other sexually transmitted diseases or to violence, and to other life threatening conditions of life, is another aspect of poverty itself. And so once can see this two way direction. Poor health leading to poverty Poverty leading to poor health. Whenever you have the arrows working in both directions, you have the possibility of a vicious spiral. Poverty, poor health. Poor health, even more poverty. More poverty, worse health. Worse health, even worse economic outcome. But whenever you have a vicious spiral you generally have the possibility of a virtuous spiral as well. Disease control raising income, higher income improved health, further improvement of health. Even yet further improvements of income in a virtuous spiral, exactly the opposite of the vicious downward spiral. It’s part of the effort of health the policy to break the vicious circle that traps people in a poverty disease trap and to make it a positive spiral of a health development upward spiral. So how can this be done? How can one intervene to control disease and thereby start the virtuous spiral? First of course is implementing what the health ministers called for back in 1978 in Alma Ata. They called for a primary health system for all, and implementing that basic primary health system is a crucial first step. Second is helping poor communities to have better nutrition. Part of that may not be directly in the health sector but in the agriculture sector. More productive farmers growing more food will support healthier diets. The community may generate a surplus that can be used for school feeding progr, programs for example. And therefore, agricultural interventions can play a role not only in agriculture and income, but also in reducing the disease burden. Local infrastructure, is another kind of investment not in the health sector per se but in safe drinking water and sanitation in. Power supplied which is vital for everything. Electricity to run the refrigerator in the clinic to keep the vaccine supply chain adequate to ensure that doctors have the facilities. Water to pump the irrigation water to improve agriculture. And a thousand other uses of electricity absolutely vital to improving overall health. Mobile phone connectivity, internet connectivity. We don’t think of those as health interventions per se. But communities that have access to phones have access to better health. They can call the doctor, they can call the health worker, they can call the ambulance and so investments in infrastructure extremely important. Education at all levels absolutely essential just so individuals understand how to seek help. But also, education raises incomes, we know that higher incomes for all the reasons we’ve discussed improve health outcomes as well. And local business development by raising the incomes of the community also cut that downward spiral of poverty and disease. How far do we have to go we have a ways but we’ve made also a lot of progress have a look at the data on the mortality rates of children under the age of five. Back in 1990, 12 million children under the age of five died. By 2010, the number was under 8 million. This is a huge, huge victory for public health. It is still 7.6 million too many. It’s still multiple and preventable tragedies, but there’s progress. There’s very substantial progress in reducing the mortality rates. If you look at the next graph, those same mortality rates are put in terms of numbers per thousand live births rather than the aggregate number of millions. And this is quite important as well. In 1990, on average in the world, 88 of each 1,000 children did not live to their first, to the fifth birthday.

By the year 2010, that rate had declined to 57. Per thousand. Still, a high number, still a number of deaths that can be cut sharply. But the under five mortality rate is falling sharply. Now remember, we also have an important clue where we need to put the extra special effort. If you look at the total number of deaths in the year 2010, the 7,600, more than 6,000 of those deaths were in just two regions, Sub Sahara in Africa and Southern   Asia. These are the epicenters not only of overall poverty but the epicenters of the disease burden and of the preventable and treatable diseases that could reduce this amount of suffering. And where are poor people succumbing to what kinds of conditions? That is shown by the estimates of the causes of deaths of children under five. And when you look at this chart, the 100% of that’s allocated in proportions to different diseases. What you see as the overwhelming message of this chart is this still very high burden of communicable, that is infectious diseases that can be spread from individual to individual. Diarrhoeal disease, pneumonia, measles, malaria, other infectious diseases, are a very large part of these deaths. What you also see are the number of deaths of children just in childbirth. As newborns, or neonates. And in the first four weeks of life. In the very vulnerable conditions just after birth. And so we see birth asphyxia. And the trauma, prematurity. A severe neonatal infections. A whole cluster of a causes of death related to childbirth and very often to the lack of sanitary conditions that face mothers giving birth. Threatening their own lives and threatening the survival of their children. Well, this is a, a good start for us in terms of understanding what to do. We have a poverty disease trap, each feeding on the other. Poverty feeding disease, disease feeding poverty. We know that this is heavily concentrated in Sub-Saharan Africa and in South Asia, we know that it’s heavily concentrated in diseases that are infectious and communicable. Or in conditions related to childbirth, or as a consequence in addition of chronic under-nutrition. So this gives us ideas where should the focus be how should we proceed? Building a primary health system that is responsive to those specific challenges is in essence the source and, and the starting point for addressing this wholly solvable but continuing crisis. We’ll now look at how that primary health system in a low income setting can best be designed

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