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

 

 

Disease Research Funding: Slicing and Dicing

Illness is expensive, and we spend huge amounts combatting disease, starting in the laboratory. The National Institutes of Health (NIH) is the largest funder of biomedical research in the world; its 2006 annual budget was $28.5 billion3. Yet, despite the staggering sum it and other organizations of its ilk dole out, money is still tight. The fierce competition for research funding has given rise to specialized disease advocacy groups that have reshaped the landscape of medical research, especially in the United States.

Allocating research funds isn’t as intuitive as it appears, and the money doesn’t always go where you’d think. Diseases that get the most funding aren’t necessarily those that kill the most people, or even those that infect the most. While disease burden, the cost of a disease in terms of both economics and mortality, is roughly related to the amount of funding a disease receives, both in the US and abroad, many diseases are underfunded or overfunded based on their impact2,3,4,6,7. For example, nearly a quarter of NIH funding (24.3%) in 2004 went to AIDS research. AIDS received about $2.9 billion, far outstripping the next highest, diabetes, at a little more than $1 billion. However, although AIDS research got the greatest amount of funding, it is the 16th most common cause of death in North America; the number one cause of death, ischemic heart disease, was allocated only 3.3% ($398 million) of NIH funds3.

The squeaky wheel

Breast cancer could be the poster disease for the fluctuations and fickleness of funding and the importance of advocacy. Breast cancer awareness and advocacy started in earnest in the 1970s, and was quickly linked with women’s liberation. Though it appears tame now, early breast cancer advocates were breaking cultural taboos against discussing cancer and breasts in public, and successfully harnessed the power of the sexual revolution to call attention to the disease. By the 1980s, breast cancer advocacy had become professional, with sustained lobbying, fundraising and publicity efforts, creating the first modern disease advocacy movement. Yet as recently as 1989, the US allocated only $74.5 million to breast cancer, less than 5% of what was spent on AIDS research, which, at the time, killed half as many people per year in the US. In response, breast cancer advocates marshaled a huge grassroots movement, gathering 2.6 million signatures in support of the National Action Plan on Breast Cancer in 19935.

research funding
Strength in numbers.

Their decades of hard work have paid off. In 2004, breast cancer was the fourth most highly funded area of disease research in the US, with $718 million in NIH funding3. In fact, they may have been too successful. There is now concern that the disease may be overfunded, relative to other more lethal cancers2,5; for example, 85% of those with breast cancer will survive, while 85% of those with lung cancer will not. Despite this tension, the breast cancer movement has clearly demonstrated the power of professional advocates effectively wielding data, visibility and celebrity, and has become a model for disease advocacy internationally5.

Gets the grease

Single disease interest groups became a force in American politics in the 1980s and 1990s, with the number of large non-profits focusing on disease doubling in the 1990s alone. Their influence has radically changed disease research funding, not only for the patients they represent, but also for all those suffering from illness. In their wake, patients have become viewed as the primary beneficiaries of research funding (as opposed to researchers or the public), and their moral worthiness as recipients has become increasingly important in funding decisions. The emergence of powerful disease interest groups has also started an advocacy arms race; greater lobbying budgets mean greater research funding. Every $1,000 spent on lobbying is associated with a $25,000 increase in research funds the following year. Patients without advocates are increasingly being outstripped in the competition for funding, potentially leaving the traditionally marginalized more vulnerable than ever1.

Advocacy groups have become an essential part of medical research funding, and they have been massively successful in shaping government funding priorities. Yet they also present a challenge, creating a chorus of demands that can make it even more difficult for overlooked groups to be heard. Amidst the clamor and all the slicing and dicing, it’s important to remember that there is only one pie and everyone wants a piece.

References

  1. Best, R.K. (2012). Disease politics and medical research funding: three ways advocacy shapes policy. American Sociological Review, 77:780-803.
  1. Carter, A.J.R., & C.N. Nguyen. (2012). A comparison of cancer burden and research spending reveals discrepancies in the distribution of research funding. BMC Public Health, 12:526.
  1. Gillum, L.A., C. Gouveia, E.R. Dorsey, M. Pletcher, C.D. Mathers, C.E. McCulloch, & S.C. Johnston. (2011). NIH disease funding levels and burden of disease. PLoS One, 6:e16837.
  1. Lamarre-Cliché, M., A.M. Castilloux, & J. LeLorier. (2001). Association between the burden of disease and research funding by the Medical Research Council of Canada and the National Institutes of Health. A cross-sectional study. Clinical & Investigative Medicine, 24:83-89.
  1. Lerner, B.H. (2002). Breast cancer activism: past lessons, future directions. Nature Reviews, 2:225-230.
  1. Luengo-Fernandez, R., J. Leal, & A.M. Gray. (2012). UK research expenditure on dementia, heart disease, and cancer: are levels of spending related to disease burden? European Journal of Neurology, 19:149-154.
  1. Xu, G., Z. Zhang, Q. Lv, Y. Li, R. Ye, Y. Xiong, Y. Jiang, & X. Liu. (2014). NSFC health research funding and burden of disease in China. PLoS One, 9:e111458.

Image source: Creative Commons, https://www.flickr.com/photos/usaghumphreys/15433169855/sizes/l