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

 

 

The Good Samaritan: Religion and Epidemics

The parable of the Good Samaritan, the story of a man coming to the aid of a beaten and bleeding traveller ignored by other passersby, is a mainstay in the teachings of Christianity. The Good Samaritan embodies a common theme in the world’s faith traditions, the idea that we should look beyond social distinctions and self-interest to help those in need. It is a plea to lead by example, to live by the Golden Rule. At its best, organized religion achieves this kind of grace, and sets an inspirational example.

Do unto others

The relationship between religion and epidemic disease is, to put it mildly, complicated, and at times even contradictory. In the name of religion, some have denounced the sick, arguing that the spreading illness (i.e. HIV/AIDS) is a curse from God, and have impeded public health efforts. Religious cultural practices, particularly funerary rites involving contact with the remains, have inadvertently helped spread disease, such as Ebola4. But on the other hand, religious groups have also done exactly the opposite: tirelessly work to dispel the belief that epidemics are divine plagues, promote preventative practices like condom use, and tackle the challenges of illness on the ground. The work of faith-based organizations (FBOs) has been essential for the care and support of people living with some of the most intractable and frightening epidemics of the modern era, including HIV and Ebola1.

Throughout the current Ebola epidemic in West Africa, FBOs have played an important role in stemming the tide of the outbreak. Many have established medical missions, clinics staffed by foreign medical professionals, usually on a short-term basis2, in the affected region. This work demands compassion and courage, because the risks are high. The first two American cases, Dr. Kent Brantly and Nancy Writebol, contracted the disease while treating patients in Liberia at a mission run by the FBO, Samaritan’s Purse. Both survived and Brantly has publicly pointed to his faith as his inspiration, professionally and personally. After recovering, he has continued to selflessly combat the disease, setting a startling example of individual belief and bravery. Brantly had donated his plasma (infusion with the plasma of an Ebola survivor is a potential treatment for Ebola) to three patients, another medical missionary, Rick Sacra, and two infected Texan nurses, Nina Pham and Amber Vinson5.

good samaritan
The good fight.

As you would have them do unto you

As mentioned in my recent post on meningitis, by creating large, diverse groups of people, pilgrimages can present a major public health risk, and many are enormous. Each year, more than 5 million Catholics visit the Sanctuary of Our Lady of Lourdes in France. The Hajj, the Islamic holy pilgrimage to Mecca, annually draws millions of Muslims from across the globe. Perhaps the most impressive in sheer numbers is the Kumbh Mela, which occurs every three years, when Hindus travel to the holy Ganges River. During the course of celebrations in 2007, 70 million pilgrims visited Allahabad, a single city on the river’s banks, and in 2001, the movement of people was so great it could be seen from space. These incredible aggregations of people have indeed led to disease outbreaks; in fact, it was a frequent feature of the Hajj into the 20th century3.

And yet. Religious mass gatherings (a mass gathering is a large number of people attending an event at a specific site for a finite time) have overcome these very real dangers to become important examples of public health preparedness and planning in the 21st century. In particular, the Saudi Arabian government has gone to staggering lengths to address the difficulties of hosting the Hajj. Within the immediate vicinity of the holy sites, there are 141 primary health-care centers and 24 hospitals, with a total capacity of nearly 5,000 beds, including 547 beds dedicated to critical care. There are more than 15,000 doctors and nurses on staff. One hundred and thirty-six of these healthcare centers have the latest emergency management medical systems, and are staffed by over 17,000 specialized personnel. Incredibly, health services are provided at no charge3.

These herculean efforts have provided important information about institutional prevention and preparedness for mass gatherings, religious or secular (i.e. the Royal Wedding, which drew a crowd of more than 1 million people in London). The involvement of so many countries (more than 180 countries are often represented at the Hajj) has also promoted international cooperation in prevention work, and encouraged global health diplomacy3.

Epidemic disease does not always bring out the best in humanity, including religious groups. Fear can be an ugly thing. But when religious organizations are able to look past difference and disagreement and see the need of the suffering, it is an awesome demonstration of their ideals. Their work is a powerful reminder that to be good, you must do good.

References

  1. Green, EC. (2001). The impact of religious organizations in promoting HIV/AIDS prevention. The World Bank. Web. 31 December 2014.
  1. Martiniuk, ALC, M Manouchehrian, JA Negin, & AB Zwi. (2012). Brain gains: a literature review of medical missions to low and middle-income countries. BMC Health Services Research, 12:134.
  1. Memish, ZA, GM Stephens, R Steffen, QA Ahmed. (2012). Emergence of medicine for mass gatherings: lessons learned from the Hajj. Lancet Infectious Disease, 12:56-65.
  1. Osterholm, MT. “Why it’s harder to contain this Ebola epidemic”. Chicago Tribune. 4 August 2014. Chicagotribune.com. Web. 3 August 2014.
  1. Ungar, L. Ebola survivors speak of suffering, service, faith. USA Today. 8 November 2014. Web. 5 January 2015. http://www.usatoday.com/story/news/nation/2014/11/07/kent-brantly-to-speak-about-medicine-faith/18600745/

Image source: Creative Commons, http://en.wikipedia.org/wiki/Ebola_virus_epidemic_in_West_Africa