Mike Rowson gives the facts and figures about poverty and health and suggests what health professionals should be doing about it

Poverty is the number one killer in the world today, outranking smoking as the leading cause of death.¹ This is hardly surprising given the number of people in the world who survive on meagre incomes, often in appalling conditions. This article briefly surveys several areas, including definitions of poverty and the numbers of people who are poor; the causes of poverty; the links from poverty to ill health; and what can be done to tackle poverty both inside and outside the health sector.

How many people are poor?

Income poverty lines

Poverty is often defined in terms of a person's income or the amount of goods they are able to consume. For example, the World Bank has set the international poverty line at an expenditure level of $1 for every person a day.2 This figure represents the minimal amount on which a person can fulfil his or her physical needs, and a person is considered to be living in "absolute poverty" if his or her income falls below this line. By this measure, at the present time about 1.2 billion people are living in absolute poverty in developing and transition economies. The poverty line is calculated using "purchasing power parities," which take into account difference in prices in goods in different countries, and so allows us to compare poverty levels internationally.

Table 1 shows the latest poverty figures for the different regions of the world. The picture contains both positive and negative elements. The number of people living on under $1 a day declined from 1993-6 but rose again by 1998 as a result of the effects of the global financial crisis which started in 1997. However, if China is excluded, the number of people in poverty has actually been rising steadily since 1987, although the proportion of poor people in relation to the total population - measured by the headcount index - has fallen slightly from 28% to 26.2%.²

The global picture then is one in which successes in poverty reduction in east Asia have been countered by increasing numbers in poverty in subSaharan Africa, south Asia, Latin America, and the transition economies. Average income levels in subSaharan Africa are now lower than they were at the end of the 1960s.3

The international poverty line gives us a convenient way of taking a snapshot of poverty in different countries and looking at trends over time. However, it is a very blunt instrument for measuring a complex phenomenon.

• It does not take into account cost of living differentials within countries. $1 will buy different amounts of goods in urban and rural areas. For example, food may cost more in cities.
• It does not show who lives in permanent and who lives in temporary poverty.
• It does not consider the distribution of income within the household-gender inequality means that men usually consume most of the household income.
• It only values goods which are delivered on the market. In many poor countries people grow and rear food and animals for their own consumption, a process which is not captured by measures of income and consumption based on the measurements of the purchase of goods sold as commodities. ⁴

Definitions of poverty

Non-income aspects of poverty

A focus on income is not always helpful when we are trying to think of ways to tackle poverty. Take a standard definition of absolute poverty (from the World Bank's World Development Report for 1980) as "a condition of life so characterised by malnutrition, illiteracy, and disease as to be beneath any reasonable definition of human decency." This definition does not spotlight lack of income as a characteristic of poverty. Rather, it concentrates on what it means to be in a state of poverty - to lack food, to be uneducated, to lack access to basic health care. Income is helpful as an instrument in obtaining such basic necessities, but it is only one instrument among many. Basic health care and education could, for example, be provided by the state.

This broader definition of poverty (often called human poverty as opposed to income poverty) requires different sets of indicators to be used to describe it. These might include access to health services; clean water and sanitation; life expectancy; infant, child, and maternal mortality rates; literacy levels; and so on. Many of these indicators are closely correlated - if you are below the poverty line you probably live in a community without access to clean water. But this is not always the case, and some countries have had greater success in reducing elements of human poverty than income poverty.⁴

Any attempt to measure poverty by drawing a simple line without a reference to social standards or factors other than income is fatally flawed. People's perceptions of poverty tend to change as countries get richer: in this sense the definition of poverty will always depend on what people, in a particular society, at a particular point in time, perceive as poor. This debate has particular relevance for already developed countries such as the United Kingdom.

The causes of poverty

In line with the broad definitions above several factors interlock to cause poverty.⁵ These include:

• Lack of income and assets.
• Isolation. Poor women can often spend many hours a day fetching water for the household, diverting them from income generation and childcare activities.
• Physical weakness. Illness can prevent the poor from earning an income and push them further into poverty.
• Powerlessness. The poor have little access to justice (important in disputes with employers or over land rights, for example).
• Vulnerability. Vulnerability may be provoked by a range of events and may be temporary in nature. However, during longer periods of economic crisis or, for example, after the death of the household wage earner, assets might not be replaced and may be eaten up completely, making people more vulnerable and pushing them deeper into poverty.

Poverty and health

Poverty and disease are inextricably linked.⁶ Table 2 illustrates this by showing the relationship between poverty and health in one country - Malaysia. The state with the lowest incidence of poverty has the lowest (best) infant mortality rate. The infant mortality rate measures the number of deaths in the first year of life per 1000 live births. The state with the highest incidence of poverty has the highest (worst) infant mortality rate.⁷

Most of the illnesses associated with poverty are infectious diseases, such as diarrhoeal illness, malaria, and tuberculosis. All of them are associated with the lack of income, clean water and sanitation, food, and access to medical services and education which characterise poor countries and communities. The diseases are linked to undernutrition and children are most susceptible to them (see table 3). The environmental, social, and dietary changes produced by industrialisation and urbanisation are leading to higher rates of diabetes, hypertension, heart disease, and respiratory illness among both the urban poor and not so poor.⁸

There is in fact a two way relationship between poverty and ill health, with disease often further impoverishing the poor. Illness prevents people from working, or affects their productivity, lowering their income. The costs of obtaining health care can also be substantial, both in terms of time off from work (clinics are often a long distance from the household) and in terms of money spent on services: it is estimated that between 1990 and 1994, 21% of previously non-poor households in Bangladesh slipped into poverty as a result of health-related causes.⁶

Tackling poverty and disease

Some countries have, however, managed to tackle the diseases of poverty even though they themselves remain at comparatively low levels of development. Some countries (notably the Indian state of Kerala, China, and Sri Lanka) have levels of life expectancy far above much richer developing countries, such as South Africa, Brazil, and Gabon. There are several reasons for the success of these poor countries in achieving good health at low levels of per caput income.¹⁰ They include:

• High levels of female literacy. International research has shown that the higher the proportion of educated girls in the population the better health indicators are. Women with better education are more likely to command higher incomes, take on board health education messages, and to demand better health care, all of which can have beneficial outcomes for themselves and their children.
• Fewer income inequalities. Where the benefits of growth are more evenly distributed, the poor will tend to gain more than the rich, reducing poverty (and the ill health associated with poverty) to a greater extent.
• Government commitment to providing health, education, and social security services, and making them available to the poor.
• Higher levels of public participation in political life. This has the effect of making government more responsive to the health and other needs of poor and vulnerable groups.

Conclusions

Health professionals have a key part to play in eradicating poverty. Firstly, they need to make sure that interventions inside the health sector benefit the poor. Too often government health expenditure is skewed towards urban hospitals which disproportionately serve the rich. Secondly, they need to make sure that in their everyday relationships with patients they treat the poor as well as anyone else. One of the commonest complaints from poor people using health services is that health professionals treat them with disrespect and offer them substandard treatment.¹¹ Training to stamp out this kind of prejudice should be mandatory for health professionals.

Finally, health professionals need to promote interdepartmental cooperation and action by governments to promote better education, water, and sanitation and other services which improve the lives of the poor. The diseases of poverty cannot be tackled without concerted economic and political action. This means justice and equality for the poorest people within our societies. You can help make a difference by getting involved.

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