Disease and Poverty: The Hidden Cost of Being Poor

We tend to think of disease as sort of natural disaster, like a kind of biological tsunami. While that’s true to an extent (some amount of disease is unavoidable), this view is dangerous because it suggests that no one is to blame for disease outbreaks, and that they cannot be prevented. And that—to put it mildly— is a bunch of hogwash.

In health, as in everything, the game is rigged in favor of the rich. It turns out that it’s not just the big top-down social structures that empower the wealthy. Inequality affects everything, right down to our immune system, stacking the deck from the ground up. The socioeconomic class you were born into directly relates to your chances of survival. That’s true not just in the near-term, meaning whether or not you survive childhood, but throughout your life.

The meek’s inheritance

Poverty is one of the greatest (arguably the greatest) causes of illness and premature death around the world. Poverty is a public health double whammy: it leaves people more vulnerable to disease by depriving them of adequate food, water, shelter, and support, and it prevents people from accessing healthcare when they do fall ill1,7. Living in poverty keeps people from getting educated, making them more likely to participate in risky health behaviors like smoking, because they do not understand the danger. It also limits choice. For example, the poor often have limited access to healthy food options, leaving them more likely to eat calorie-dense, high-fat food that deteriorates their health7.

Not only can being poor prevent you from getting medical attention, getting treated can also make you poor. The poor often cannot afford healthcare, if it’s available at all. But the expense can also cause an economically secure family to fall into poverty, which then leaves them more likely to get sick in the future, creating a terrible cycle. It’s easy to see how this happens. Healthcare expenses add up quick, from the cost of medicine to the wages lost due to sickness. These costs can spell disaster. The severe illness or death of the main breadwinner can be financially catastrophic for the household, and may permanently impoverish the remaining family members7.

As with everything, deep economic misfortune is not shared equally. The world’s poorest citizens are concentrated in areas that have been historically exploited and disenfranchised, including sub-Saharan Africa and eastern and southern Asia5. In high-income countries, a legacy of racism and xenophobia have left minorities much more likely to live in poverty. For example, in America, 45.8% of young black children (under age six) live in poverty, compared to 14.5% of young white children3. The global burden of social and health inequality falls particularly hard on women, aided by gender inequality2,7. Worldwide, women suffer from a higher rate of disease than men, especially very poor women7.

disease and poverty
What a weight to carry.

Live poor, die young

The World Health Organization estimates that 45% of the global disease burden is caused by diseases of poverty5. That’s right, the connection between poverty and illness is so powerful that there is an entire group of diseases defined by the association: diseases of poverty. These include HIV/AIDS, tuberculosis (TB), malaria, and the so-called neglected tropical diseases, like dengue, rabies, and Chagas disease2.

These conditions take a massive toll, measured in the millions and billions. Of the 2.7 billion people living in poverty around the world, more than 1 billion suffer from neglected tropical diseases1. In 2010, HIV/AIDS killed 1.5 million people, TB killed 1.2 million, and malaria killed 1.17 million. In 2012, 91% of the deaths from malaria occurred in Africa, and 86% involved children under the age of five2.

The conditions of poverty itself also give rise to a suite of deadly conditions. These include malnutrition, diarrheal diseases (which claim a staggering 1.8 million lives per year), and respiratory infections due to air pollution.

Chronic diseases, like cancer, cardiovascular disease and diabetes, also disproportionately affect the poor. The poor are more at risk of getting a chronic disease, and of dying from it early. This inequality is often most striking in high-income countries like the United States. These conditions can last for decades, and require long-term care, which can greatly increase their cost and exacerbate the negative poverty-healthcare cycle I talked about earlier7.

What is especially tragic about these conditions is that most of them can be prevented with established approaches or treated with existing medicines2,5. They should not happen. But, as discussed above, healthcare and health education are often not available to those who need it most.

The lasting effects of poverty

Poverty in childhood affects health for a lifetime, even if you stop being poor. The conditions common to poverty, like malnutrition, can have lasting effects like impaired growth or cognitive development2. However, it’s more than that. All else being equal, children who are raised in poverty still have a greater risk of developing health problems later in life than those who are not. These include many diseases that are common in America: heart disease, stroke, and some cancers4.

Scientists have not determined what drives this; some have speculated that the conditions of poverty prime the immune system for later illness4. For now, it’s clear that even if you somehow claw your way out of poverty, you may still suffer its costs.

The toll of history

Disease does not happen in a vacuum. It is a symptom of historical inequality and structural violence, including racism, sexism and xenophobia1, and it is often the direct result of poverty. Until those of us in positions of relative privilege take responsibility and address these underlying causes, the world will not be free of the enormous burden created by preventable illness and death. And—make no mistake—we will all be to blame.

References

  1. Alsan, MM, M Westerhaus, M Herce, K Nakashima, and PE Farmer. 2011. Poverty, global health and infectious disease: lessons from Haiti and Rwanda. Infectious Disease Clinical North America, 25:611-622.
  2. Bhutta, ZA, J Sommerfeld, ZS Lassi, RA Salam, and JK Das. 2014. Global burden, distribution, and interventions for infectious diseases of poverty. Infectious Diseases of Poverty, 3:21.
  3. Economic Policy Institute. 2012. The State of Working America: Key facts. Washington, DC. Economic Policy Institute. 13 December 2016. http://stateofworkingamerica.org/fact-sheets/poverty/
  4. Miller, GE, and E Chen. 2013. The biological residue of childhood poverty. Child Development Perspectives, 7:67-73.
  5. Stevens, P. 2004. Diseases of poverty and the 10/90 gap. International Policy Network.
  6. Sumner, A. 2012. Where do the poor live? World Development, 40:865-877.
  7. World Health Organization. Chronic diseases and poverty. Web. 8 December 2016. http://www.who.int/chp/chronic_disease_report/part2_ch2/en/

Image Credit

Julie, D. File DSC00930 Burma Shan State Table Land Heavy Transportation on the Path to Indein. Creative Commons. 13 December 2016. https://commons.wikimedia.org/wiki/File:DSC00930_Burma_Shan_State_Table_Land_Heavy_Transportation_on_the_Path_to_Indein_(4679157162).jpg

 

 

Zika Virus & Microcephaly: Family Planning

Aliases: Zika, Zika virus disease, ZIKV

Zika seems have to come out of nowhere, erupting from the ether to dominate the landscape of global health. The epidemic is an unhappy reminder that disease preys on the weak, an unwelcome addition to the discordant chorus of ailments plaguing those in poverty. That can make it dangerously easy to ignore.

Zika was discovered in Uganda in 1947. There were less than 20 reported cases in the following 50 years. During that time, Zika may have been hiding in plain sight. The symptoms of the disease are generally very mild, and many cases go unreported. When symptoms do occur, the disease looks a lot like dengue and chikungunya, and occurs in similar regions (because the same mosquitoes aid its spread), making accurate diagnosis of Zika a serious challenge2,4.

After this lull, Zika came back with a vengeance. In 2007, there was an outbreak of the disease on the Western Pacific island of Yap2,4. Six years later, in 2013, there was an outbreak of at least 30,000 cases in French Polynesia2. Smaller outbreaks broke out across the Pacific islands through 20144 and by late in the year, Zika reached Brazil4. From there, the disease has spread rapidly. As of this posting, the CDC has a travel notice in effect for Cape Verde, Mexico, and most of the Pacific Islands, Caribbean, Central America, and South America6.

zika virus
Ouch.

During the current outbreak, it has become clear that Zika can cause microcephaly in fetuses affected by their mother’s illness. Microcephaly is a malformation that results in an abnormally small brain and skull5. In the wake of this discovery, many health experts are advising that women living in affected areas delay pregnancy1,3. That seems like a reasonable suggestion, but it leaves a critical question unanswered: how?

The regions most affected by this outbreak, Central and South America, have notoriously strict regulations on the tools of family planning– contraception and abortion– especially for unmarried women. There are only 3 countries in the region where abortion is broadly legal (Uruguay, Guyana, and French Guiana)1, and birth control is generally difficult to come by1,3. The low rates of contraceptive use (some of the lowest in the world), along with high rates of sexual violence against women1,3, mean that 18% of births in Latin America are to teenage mothers, and an estimated 50% are unplanned1.

Without ready access to birth control, asking women to delay pregnancy isn’t just an unfair request, it is an impossible one. And it places the responsibility of stemming an epidemic squarely on the shoulders of a disenfranchised population: the women of Latin America. That is asking too much.

Cause: The Zika virus is usually transmitted by mosquitoes. It can be spread by several species of mosquito, including species in the troublesome Aedes genus that also transmitted the dengue and chikungunya viruses. There are several other possible means of spreading Zika. Four reports suggest sexual transmission. Blood transfusion, organ or bone marrow donation, and neonatal (from mother to newborn) transmission have all also be suggested as possible transmission routes4.

Consequence: Zika is generally a very mild or even asymptomatic disease. The most common symptoms are fever, rash, arthritis, conjunctivitis, and fatigue. Most patients make a full recovery; only four deaths have been attributed to Zika, in addition to the newborns that have died from microcephaly within a day of being born. Neurological complications, including microcephaly in infants and Guillain-Barré syndrome in adults, occur in a small number of cases4.

Cure: There is no specific vaccine or treatment targeting Zika. Symptoms are treated, and patients are given fluids. Prevention efforts depend on mosquito control and personal protection from mosquitoes to suppress disease spread4.

References

  1. Alter, Charlotte. “Why Women in Latin America Can’t Follow Zika Advice to Avoid Preganancy”. Time Online. 28 January 2016. Web. 5 June 2016.
  1. Ioos, S. H.-P. Mallet, I. Leparc Goffart, V. Gauthier, T. Cardoso, and M. Herida. 2014. Current Zika virus epidemiology and recent epidemics. Médecine et maladies infectieuses, 44:302-307.
  1. McNeil, Donald G. “Growing Support Among Experts for Zika Advice to Delay Pregnancy”. The New York Times Online. 5 February 2016. Web. 24 May 2016.
  1. Musso, D, and DJ Gubler. (2016). Zika Virus. Clincal Microbiology Reviews, 29:487-524.
  1. Persutee, W.H. 1998. Microcephaly- no small deal. Ultrasound in Obstetrics & Gynecology, 11:317-318.
  1. Zika Travel Information. Centers for Disease Control and Prevention. 26 May 2016. Web. 7 June 2016.

Image credit: Creative Commons, the image is in the public domain