Poverty leads to conflict and conflict leads to greater poverty and an inability to effectively respond to health disasters

The world is currently trapped in a humanitarian crisis of epic proportions. This crisis is poverty. Article 25 of the Declaration of Human Rights states, ‘Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family.’ [1] Despite this 3.2-3.8 billion people (51-60% of the world’s population) live below the ‘Ethical Poverty Line’, defined as the income level below which further income losses materially shorten life expectancy [2]. Every year 10 million children in the developing world die from preventable causes including diarrhea, pneumonia, measles, malaria and HIV/AIDS: in over half of these deaths malnutrition is an underlying cause [3].

These deaths can be directly linked to poverty because with the appropriate resources they are preventable. As illustrated on the graph below [4], poverty is a humanitarian crisis of epic proportions. The poverty related child deaths in just one year reach a death toll exceeding that of World War II.

Figure 1: Graph illustrating the death toll of 20th century atrocities and the deaths of young children from poverty in one year

Many of the world’s current humanitarian crises are a result of underlying global poverty. Collier’s studies show that low income and slow growth make a country prone to civil war [5]. A country with a gross domestic product (GDP) of US$250 per capita has a 15% probability of a war in the next five years. A country with a GDP of $600 per capita has approximately half of this probability [6]. Natural disasters are likely to impact poor countries more severely because poorly developed infrastructures and lack of resources make preparation and appropriate response difficult. If Haiti were not so poverty-stricken, the country may have been able to improve its physical infrastructure to prevent the terrible devastation caused by the recent earthquake. Poverty produces poor health and makes communities more susceptible to disease but contrarily also means effective treatment is unaffordable [7]. Conflicts, which are more likely to occur in poverty-stricken countries, both cause and exacerbate disease epidemics A vicious cycle is then created: poverty leads to conflict and conflict leads to greater poverty and an inability to effectively respond to health disasters.

Poverty has many causes but there is increasing recognition that international policy can have a negative or positive impact depending on its nature [8]. The World Bank has promoted a predominantly neo-liberal approach to poverty reduction. This approach relies on the trickle down of wealth through society to alleviate poverty [9] with social safety nets to protect the poorest [8]. According to the Bank’s definition of poverty the number of people living in extreme poverty has decreased. [10] The Bank’s criteria have been criticized however, since when the ethical poverty line is used the numbers have increased by 22-30% in the last thirty years [2]. The reality of this trickle down effect is challenged by the fact that in America, one of the richest countries in the world, with a predominantly neo-liberal approach to policy, one quarter of children lived in officially defined poverty in the year 2000 [11].

In the 1980s neo-liberal policy was introduced in many developing countries in the form of Structural Adjustment Programs. These policy packages developed by the World Bank and IMF reduced the role of the state and encouraged privatization. User fees were introduced in these countries health systems resulting in less people accessing healthcare [9]. Market liberalization was encouraged but a study published by the World Bank later found that it correlated with a decrease in income growth in the poorest 40% of the population [12]. A neo-liberal market approach is efficient at making the rich richer but not so efficient at making the poor richer. In 2000 the US’s top four hundred tax payers had a combined income that exceeded the combined income of Botswana, Nigeria, Senegal and Uganda [13].

It is important to note that the recommended neo-liberal policies have not been uniformly implemented. Some international policy disregards neo-liberal recommendations in order to favor the interests of the rich. The Trade Related-aspects of Intellectual Property Rights (TRIPS) agreement jeopardizes the generic drug industry in developing countries in order to protect the profits of the pharmaceutical industry [14]. It extends patents in spite of the fact that the current patent system is economically inefficient and causes losses of a much larger scale than those caused by tariffs and trade barriers [16]. Another example of the hypocrisy in international trade related policy is subsidies. Although the World Trade Organization has encouraged poor countries to stop subsidizing their farmers the rich countries continue this practice. European citizens are currently paying $2 per cow in subsidies when half the world’s population lives off less. It is impossible for poor farmers to compete with farmers in European countries who enjoy an average of $14,000 a year in subsidies [15]. Many countries are also paying more in debt than they receive in aid. These debts became un-payable partly because of the subsidies introduced by rich countries in the 1980s [9]. Protectionism and tariffs persist and it may be that fairer trade liberalization would have more benefits for the poor [17].

However even if proven to be effective, a pure neo-liberal approach is arguably not the most efficient poverty reduction strategy. Currently each $1 of poverty reduction acquired in this way requires $166 of additional global production and consumption with the associated environmental consequences having the biggest impact on the poor [7]. There is also evidence to suggest that the wealth inequality inherent in neo-liberalism is itself health damaging. Wilkinson’s research indicated that societies with more unequal distributions of wealth generally have poorer outcomes across a range of indicators [18].

It is irresponsible to place the lives of millions in the invisible hands of the market rather than in the hands of governments who can act to solve the problem. The resources already exist to alleviate extreme poverty. The United Nations Development Program estimated the additional cost of achieving basic social services for all in developing countries at about $40 billion a year between 1995 and 2005. This is less than 0.2% of world income [2]. Ending poverty needs to be prioritized and economic growth needs to be viewed as the means rather than the end of development and as one of many tools that can be used to achieve better lives for people across the world [19].

Internationally, countries need to meet the 0.7% GDP aid commitment. International taxation needs to be considered and debt cancellation accelerated in order to redistribute wealth more equitably. Nationally the state has a role in regulating and controlling the market. Progressive taxation and universal access to health and social services can help reduce poverty [7]. As shown there is already a clearly defined alternative to the neo-liberal approach. However even if there was not human ingenuity could surely find a solution to this problem. If the human race can organize itself to enable travel and communication across the globe it can find a way to ensure everyone in the world has access to the necessities of life. Poverty is a political choice not an inevitability [2].

It is right that the world responds so efficiently and passionately to crises like the Haitian earthquake but if this response is based on horror at life needlessly wasted then our response to the lives disabled and destroyed by poverty should be amplified many times over. If governments’ commitment to a shared humanity is to be more than empty words then they need to act with the same passion and sense of urgency in the fight to end poverty as they have in the aftermath of the earthquake. This is particularly poignant considering Haiti’s long history of deprivation. Acting in the aftermath of a natural disaster is like putting a band-aid on what was already a gaping wound. A survey conducted in Haiti between 1999-2000 found that 67% of the population was living in poverty. Between 1996 and 2000 infant mortality rose from 73 to 80 per 1000 live births, an increase associated with increases in poverty, HIV and inadequate health services [20]. Increased investments should have been made long ago in infrastructure and development to alleviate the desperate poverty and silent suffering of Haiti’s people.

If we are to preserve our integrity as individuals and as nations we need to fight for the silent millions outside the gaze of the media who suffer under the weight of a global humanitarian crisis. We must be a voice for the voiceless victims of the unnatural disaster that is poverty.

Emily Wilson is a third year medical student at the University of Bristol
emsw123(at)hotmail.co.uk

References:

1. United Nations. The Declaration of Human Rights. Article 25. 1948. [Online] Accessed: 20/01/10 Available from: http://www.un.org/en/documents/udhr/

2. Gordon, D. (2004) Poverty, Death & Disease, in Hillyard, P., Pantazis, C., Tombs,

S. and Gordon, D. (Eds) (2004) Beyond Criminology: Taking Harm

Seriously. London, Pluto.

3. Jones G. et al (2003) How many child deaths can we prevent this year? Lancet 362: 65-71

4. Gordon D. (2009) Poverty, Death and Disease: and introduction to inequalities and health. Presented on The International Health Course. Bristol University.

5. Collier P. (2008) The Bottom Billion: Why the poorest countries are failing and what can be done about it. Oxford. Oxford University Press.

6. People’s Health Movement, Medact, Global Equity Gauge Alliance. Global Health Watch 2; 2008 [Online] Accessed: 20/01/10 Available: http://:www.ghwatch.org/ghw2/ghw2pdf/ghw2.pdf

7. CSDH (2008). Closing the gap in a generation: health equity through action on the social

determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization.

8. Townsend P. and Gordon D. (2002) The Human Condition is Structurally Unequal in Townsend P. and Gordon D. (eds) World Poverty: New policies to defeat and old enemy. Bristol. Policy Press.

9. Gloyd, S. (2004) ‘Sapping the poor: the impact of structural adjustment programs’ in M.Fort, MA Mercer and O. Gish (eds) Sickness and Wealth: the corporate assault on global health. Southend Press.

10. World Bank (2010) World Development Report 2010: Development and climate change. Washington. World Bank.

11. Hofrichter R. (2003) ‘The Politics of Health Inequality’ in Hofrichter R. (eds) Health and Social Justice: politics, ideology and inequality in the distribution of disease. San Francisco, John Wiley & Sons.

12. Oxfam (2000) Agricultural trade and the livelihoods of small farmers: discussion paper for DFID. Oxfam GB Policy department. [Online] Accessed: 15/01/09 Available: http://www.oxfam.org.uk/resources/policy/trade/index.html

13. Sachs J. (2005) The End of Poverty: Economic Possibilities for Our Times. London, Penguin Books.

14. People’s Health Movement, Medact, Global Equity Gauge Alliance. Medicines in Global Health Watch ; 2005-06. [Online] Accessed: 20/01/10 Available from: http://www.ghwatch.org/2005_report.php

15. Oxfam (2002) Milking the CAP: How Europe’s dairy regime is devastating livelihoods in the developing world. Briefing Paper 34. [Online] Accessed: 15/01/09 Available:

http://www.oxfam.org.uk/resources/policy/trade/downloads/bp34_cap.pdf

16. Baker D. Financing drug research: what are the issues? Washington DC, Center For Economic and Policy Research; 2004b.

17. Stiglitz J and Charlton A. (2005) Fair Trade for All: how trade can promote development. Oxford. Oxford University Press.

18. Wilkinson RG and Pickett KE (2009). The Spirit Level: Why more equal societies almost always do better. Penguin.

19. Sen (1999) Development as Freedom. Oxford. Oxford University Press.

20. Pan American Health Organization. Basic Health Indicator Database. [Online] Accessed: 20/01/10 Available from: http://www.paho.org/English/DD/AIS/cp_332.htm

Panel member Sir Iain Chalmers working in the Gaza strip in the 1960s

On Thursday 13th May 2010, the Oxford Society for Medicine held an audience-driven discussion exploring obstacles to health care delivery in the occupied Palestinian territory. The panel brought together six of the leading luminaries of the medical and surgical world, and in today’s article, Omar Abdel-Mannan, president of the OSM, and Imran Mahmud report on the event, and the current status of Palestinian health.

Palestinian health has never been in a worse state…. and it continues to deteriorate. Why and how can we use our resources here in the UK to support medical professionals in the West Bank and Gaza?

On the December 27th 2008, the Israeli Defence Force (IDF) launched Operation Cast Lead, a three week military assault on Gaza. 1366 Palestinians were killed, 313 of whom were children. International doctors, Mads Gilbert and Erike Fosse, witnessed at first hand, “the most horrific war injuries in men, women and children in all ages in numbers almost too large to comprehend” [1]. White phosphorous munitions were fired upon civilian areas in Gaza, leading to widespread severe chemical burns [2].

However, what we tend to forget is that the 18 month sea and land blockade on Gaza, prior to the IDF operation and the siege which continues to this day precipitated the collapse of Gaza’s healthcare infrastructure. This is evident by the lack of basic medical equipment, such as patient trolleys, ventilators and electronic monitors for vital signs in hospitals like Al-Shifa, where Mads and Erik worked. Infant mortality and growth stunting rates in children (representing reliable indicators of health status) have either stagnated or increased between 2000-2006 [3]. A WHO survey on quality of life in 2005 found it to be lower in the occupied Palestinian territory (oPt) than all other countries studied.

Further, malnutrition, unemployment, public curfews and restrictions on movement are daily realities. The separation wall, constructed between Israel and the West Bank and declared illegal by the International Courts of Justice, continues to impede movement of Palestinians during everyday activities, and divides neighbourhoods and households [4]. Reports of patients needing life-saving operations and critical care being denied access and women giving birth at checkpoints are commonplace [5]. The need for travel permits delays access to hospitals for patients, medical students and health workers, with commuting times increasing from 30 minutes to more than 2.5 hours on a regular basis.

Wall inside Bethlehem

Chronic exposure to violence, humiliation and insecurity has bred pervasive demoralization and despair amongst Palestinians. Yet, within this context, Palestinians have cultivated a collective social resilience to occupation in the face of daily struggles [6].

This sad state of affairs for the health of Palestinians is couched within a larger context of disjointed and inadequate public health provision and healthcare infrastructure that developed over generations of different regimes. A Palestinian Ministry of Health, established after the Oslo accords in 1994 (along with the Palestinian National Authority), inherited a neglected health service from the Israeli military after decades of degradation. Current services remain inadequate for the health needs of the people, due to continuing neglect, poor management and corruption. Israeli restrictions since 1993 on the free movement of Palestinian goods and labour across borders between the West Bank and Gaza have certainly made matters much worse. The lack of any control by the Palestinian National Authority over water, land, and the environment within the oPt has made building an effective health system virtually impossible. To compound this further, the reliance on financial assistance from a multiplicity of donors, complete with their different agendas has also resulted in programme fragmentation [7].

Erez checkpoint in Gaza

So what is the solution?
Building an effective healthcare system requires command over resources, self-determination, sovereignty and free movement of people, all absent in the Palestinian territories, particularly in Gaza. This is the argument put forward by a number of world renowned academics, doctors and surgeons in a conference organized recently by myself and a number of students at Oxford University: ‘Healthcare under siege: supporting medical education in the occupied Palestinian territories’. In this gathering the expert speakers drew on their decades of personal experiences in the oPt to expose the devastating effect of crippling economic blockades and military attacks on civilian health and access to medical care, especially in Gaza. Who are these ‘experts’? Sir Iain Chalmers – A co-founder of the UK Cochrane Collaboration, Sir Terence English – the first surgeon to perform a heart transplant in the UK in 1979, Dr. Richard Horton – Editor-in-Chief of The Lancet, to name but a few.

Some of the speakers and panellists who were present at the conference: Oxford Teaching Group Dececember 2009 L to R – Dr Knight, Dr Little, Mr Dudley, Mr Nick Maynard, Dr Marfin, Mrs George, Mr Bruce George

Oxford Teaching Group April 2008 L to R – Prof Kenwright, Mr Britton, Mr Nick Dudley, Mr Maynard, Mr George

Earlier this year in February, Dr Horton and Sir Iain Chalmers visited Gaza, gaining access with the help of the charity Medical Aid for Palestinians. In his ten minute talk, Dr Horton vividly portrayed the image of a disintegrating healthcare system and a humiliated people: “Going through checkpoints is like going through cattle gate”. One of the pressing needs, as he argued, is to systematically train medical researchers and postgraduate students to build a solid foundation of medical professionals for the future. Supporting the universities, he added, is crucial to better understand the Palestinian case, to understand their needs, and to focus on supporting human rights.

Meanwhile, Prof Colin Green from University College London (and UNESCO Chair of Cryobiology with the Ukraine Academy of Science) was a key player in the extraordinary construction of a medical school from scratch based at Abu Deis in the West Bank in 1994 (with an original intake of 34 students), which today has grown to over 800 students in four campuses. As he highlights, family practice in the area is very poor and it seems that all doctors end up in the hospitals: “We need champions of primary care,” enthused Prof Green. More specialists are also need in the region, with only 1 pathologist and 2 cardiologists in the whole of the West Bank and a clear lack of Psychiatrists.

So why should we care about this region?
I personally believe, as do all the speakers, that the UK has a special responsibility towards the people of Gaza and the West Bank, due in no part to our historical ties. The Balfour declaration of 1917, which involved Britain giving away a country that didn’t belong to us, to two different national movements, was always bound to end in tears. It is thus our politicians’ responsibility today to clean up this mess, and to uphold the promise made in that same declaration that ‘nothing would be done to harm the civil and religious and human rights of existing non-Jewish communities in Palestine’.

Wall alongside road in West Bank

By discussing the UK’s wider role and moral responsibility towards the Palestinian people in Gaza and the West Bank, I am confident that we will develop and implement innovative strategies to make a positive on-the-ground difference to civilian health, access to medical services and medical education there. Oxford Brookes University’s historic decision in March to establish a scholarship programme for Gazan students (set up with the help of Dr Iain Steadman, Director of Development and one of the attendees at the conference) is one such example of the tangible difference that can be made through academia. In fact, within hours of the conference ending, a number of enthusiastic medical and humanities students from the university had already formed a student movement aiming to push through a number of short and long term proposals; including the facilitation of twining Al Quds University medical school (based in Abu Dies) to Oxford University medical school. I very much hope that this will promote elective exchanges, the sharing of ideas and teaching materials, and act as a catalyst for similar programmes at other UK medical schools.

I couldn’t help think during the conference: Why have such distinguished members of the medical elite, with hugely successful careers in their respective fields, invested so much energy in this cause – sometimes putting their jobs on the line as a result? These are people with no political, religious or cultural affiliation to the Palestinian issue, fighting for a cause that is thousands of miles from their doorstep. The simple answer is that at the end of the day, doctors and surgeons work in the business of helping people – the original Hippocratic Oath clearly states: “I will keep them (the sick) from harm and injustice”. That is undoubtedly a political statement. All medics should be championing human rights and tackling injustice across the world, wherever it rears its ugly head.

While a political solution remains distant, ordinary Palestinians in Gaza and the West Bank continue to suffer. The physical, psychological and social well-being of Gazans will remain poor, whilst the structural impediments and barriers to development remain in place. As the WHO’s Commission on Social Determinants of Health states:

“The conditions in which people live and work can help to create or destroy their health”.

The situation is grave, but it is not impossible. Within all the darkness, beacons of light across remain bright across both sides of the wall. The Director of the Institute of Community and Public Health at Birzeit University (in the West Bank) wrote in a statement to the audience at Oxford University, that all of us can individually do something to help: by supporting medical education, by visiting the region to see at first hand the challenges of daily Palestinian life, and by advocating for justice and human rights, we can make a difference.

For me the heartfelt passion and commitment of the speakers resonated with my core values as a future doctor and reminded me of why I chose medicine in the first place. Inspired by this event, I am taking the first steps on a journey that will take me to a land of challenges and resilience. I truly believe that every medic should go the occupied territories and see with their own eyes the health of ordinary, innocent people under siege.

Omar Abdel-Mannan and Imran Mahmud are both fifth year medical students at Oxford University
omar.abdel-mannan(at)medschool.ox.ac.uk

References:

1. Gilbert M, Fosse E. Inside Gaza’s Al-Shifa hospital. The Lancet 2009; 373: 200-202

2. James Hider, Sheera Frenkel. Israel admits using white phosphorous in attacks on Gaza. The Times. 24th Jan 2009

3. Rita Giacaman Rana Khatib, Luay Shabaneh, Asad Ramlawi, Belgacem Sabri, Guido Sabatinelli, Prof Marwan Khawaja, Tony Laurance. Health status and health services in the occupied Palestinian territory. The Lancet 2009. 373; 837-849

4. United Nations. Gaza Strip inter-agency humanitarian fact sheet. March 2008 http://domino.un.org/pdfs/GSHFSMar08.pdf (accessed Aug 2, 2008).

5. Hanan Abdul Rahim, Laura Wick , Samia Halileh, Sahar Hassan-Bitar, Hafedh Chekir, Graham Watt, Marwan Khawaja. Maternal and child health in the occupied Palestinian territoriy. The Lancet 2009; 272: 967-977

6. M Rutter, Resilience in the face of adversity: protective factors and resistance to psychiatric disorder, Br J Psychiatry 1985; 147: 598–611

7. Rajaie Batniji, Yoke Rabaia, Viet Nguyen–Gillham, Rita Giacaman, Eyad Sarraj, Prof Raija–Leena Punamaki, Hana Saab, Will Boyce. Health as human security in the occupied Palestinian territory. The Lancet 2009. 373; 1133-1143

There are nearly one billion people going hungry in the world today. According to Jacques Diouf, General Director of the Food and Aid Organization (FAO): “We have never seen so many hungry people in the world.” (1)

The magnitude of the hunger crisis today encourages us to reconsider with fresh attention ideas that have existed for decades. Specifically I see an urgent need to mitigate risk by collectivizing poor peoples’ financial and agricultural resources, and stabilizing their access to credit.

I advocate a 3-step approach to improve the financial security of poor people against hunger. It includes: 1) Fostering the growth of local finance cooperatives to gain better access to credit, 2) Supporting the growth of local agricultural cooperatives to improve profitability and sustainability of commodity sales, and 3) Promoting the expansion of rural finance intermediaries in low-income countries to democratize access to reliable and affordable credit.

People pooling their financial resources in the form of a group collective is a way to avoid the risk of individual hardship. It simultaneously increases the negotiating power of the group to essential credit and insurance that benefits each individual member. Group funds can also be used as collateral for larger emergency loans to purchase food for the community. These financial collectives could be administered by an elected board of overseers. This is similar to the successful decentralized leadership style of the Panchayat Raj system in place in rural India for decades. There is a precedent in place for this idea. The concept of collective purchasing decisions has been advocated in South Africa as an approach to negotiate prices for goods and also seek redress for unsatisfactory products. (2)

A consumer collective might additionally have the purchasing power to negotiate new forms of financial agreements that serve its members in times of distress. For example, in the case of insurance, it would be interesting to see if an insurance instrument could be developed that protects people against price-shocks in marketed food. This instrument would be dispersed when market prices of key staples are a set proportion above the income of the title holder. It could be seen as a unique twist on the idea of famine insurance. (3)

Apart from financial collectives, agricultural collectives are important grassroots bodies that promote the public good. These organizations not only pool resources but simultaneously can act as negotiators with consumers. They can restrict sales to ensure proper enumeration of all members, and possibly allocate emergency funds to members and the local community during times of excessive food need. Motiram and Vakulabharanam in particular stress the importance of cooperatives in avoiding the fraudulent and corrupt practices of many local moneylenders or speculators. Small-scale farmers unfortunately rely on many of these unscrupulous lenders as a last resort source of loans. (4, 5)

Fair trade is an important mechanism to oversee such equitable sales for agricultural collectives. Fair trade specifically identifies farm cooperatives for certification in its network. Those that satisfy the entity’s guidelines are ensured advance sales, a minimum price for their goods, as well as a premium to support other social needs. (6, 7) Fair trade goods represented a 3.7 billion dollar market in 2007, a 40 percent increase from the previous year. To broaden its reach, fair trade entities such as the Fairtrade Labeling Organizations International (FLO) and TransFair USA can develop a plan to recruit and help initiate new farm cooperatives into the network. (8) Many local farmers in low-income countries may not have an idea on how to start a cooperative, or what fair trade is all about. The support of FLO and TransFair could provide the momentum to initiate a more expansive producer network.

Rural finance intermediaries are an important body to provide loans to farmers that should be extended to more low-income countries. They offer a legitimate option apart from local moneylenders who are possibly more unreliable and have a higher tendency for corruption. (9) One successful example is the Bank Rakayat Indonesia – Unit Desa (BRI UD). This is a limited-liability corporation chartered by the federal government of Indonesia in 1968. It provides individual and commercial loans to low-income rural people as well as small-scale entities like farm cooperatives. It has 2.6 million clients, an outstanding loan balance of 2.3 billion dollars, and an investment portfolio of 16 percent dedicated to agriculture. It has operated as a self-sustaining entity by having a diversified investment portfolio, lowering the barriers for loan access by having loan maturation periods of one year and application processing time of only one week, and by ensuring that loan interest rates compensate for full operational costs. (10)

The BRI-UD success story is one example of a notable series of successful microfinance enterprises that include the Grameen Bank of Bangladesh and Grama Vidiyal of southern India. These latter two examples show how far and constructively microfinance has developed in the last thirty years. Specifically, Grama Vidiyal provides loans to over 400,000 poor female clients from the south Indian state of Tamil Nadu. It has a loan portfolio of greater than 40 million American dollars, and recently in June 2009 raised 4.25 million dollars in capital through equity and not-for-profit funds. (11) Since June of 2009, the Grameen Bank has dispersed 8.1 billion dollars of funds to a base of 7.9 million clients since its inception. It has a loan recovery rate of 97.81 percent. (12)

In evaluating the policy proposals presented so far, I present a perspective where the needs of the poor can be served by a combination of open financial markets acting in coexistence with regulations that decrease financial volatility and risk. A key part of such regulation is monitoring the performance of the policy proposals I have presented.

I advocate clear quarterly timetables that track the progress of cooperative growth based on set milestones that build one upon the other. The milestones would be cooperatively decided upon by both investors and the farmers, and its terms reassessed on an annual basis by both parties. The measurement of the growth would not only be indexed to the valuation of the produce sold, but also to the well-being of the farmers in the cooperative by taking into consideration poverty-specific structural issues such as political instability and endemic disease risk in ultimately basing the cutoffs for milestone achievement. These variables include such things as the targeted rise in disposable income of the farmers, the cumulative savings of their families, and the percent of income that can be feasibly invested for school fees for their children.

In this model of assessment, financial timetables shift from a more aggressive evaluation based simply on the rate of return to investors. Instead the quantitative benefit to the stakeholder is considered as well. This change in philosophy draws from ideas such as the “blended value proposition” of sustainable markets analyst Jed Emersen who advocates combining social and economic factors in making valuations. (13)

Hunger is growing in the world, but it does not have to stay that way. Existent financial tools such as group collectives and growing market organizations such as Fair Trade provide compelling means to increase the purchasing power of the poor. Clear guidelines, financial support from major transnational and regional organizations, realistic milestone markers, and aggressive straightforward marketing to even isolated regions in low-income countries are practical ways to foster the growth of these policies into real change. By seeing this problem in a financial context, hunger will be transformed from a metaphorical scourge to an economic challenge that we can devise tools to minimize.

Vasu Sunkara is a fourth year medical student at the University of Wisconsin School of Medicine
sunkara.vasu@gmail.com

Acknowledgments

The author would like to thank Prasad Sunkara, David Marcus, the Lancet Student editors, Kusuma Sunkara, Peggy Grossman, and Carmen Gonzalez for helpful advice and access to pertinent documents.

References

1. Jenny Barchfield. “Experts: Nearly 1 billion hungry people in the world.” Associated Press. May 6, 2009. Website: http://www.google.com/hostednews/ap/article/ALeqM5gZ0PJHgjR_O-Oj1lKzmQ6qYxH3zQD980TTMO0

2. “The Right to Information”. National Consumer Forum (NCF). South Africa.Website: http://www.ncf.org.za/main.php?include=about/info.html

3. The Economist. “Famine Insurance: Hedging against the Horseman”. December 9, 2004. Website: http://www.economist.com/finance/displaystory.cfm?story_id=E1_PQRTVTG

4. Sripad Motiram and Vamsi Vakulabharanam. “Corporate and Cooperative Solutions for the Agrarian Crisis in Developing Countries”. Review of Radical Political Economics. Season XXXX. January 2009. Website: http://www.networkideas.org/alt/jan2009/Developing_Countries.pdf

5. Ravi Sharma. “Farmers in Distress”. India Frontline. Volume 15, Number 7, April 4-17, 1998. Website: http://www.hinduonnet.com/fline/fl1507/15070360.htm

6. Fairtrade Labelling Organizations International (FLO). “Generic trade standards”. Website: http://www.fairtrade.net/generic_trades_tandards.html

7. James Melik. “Food crisis hits developing world farms”. BBC World Service. February 25, 2009. Website: http://news.bbc.co.uk/2/hi/business/7905312.stm

8. Jean-Marie Krier. “Fair Trade 2007: New Facts and Figures from an ongoing Success Story”. Dutch Association of Worldshops. Website: http://www.wfto.com/index.php?option=com_docman&task=doc_download&gid=1110&&Itemid=109

9. Yaron Jacob and Benjamin McDonald. “Developing Rural Financial Markets”. Finance and Development. December 1997. Website: http://www.worldbank.org/fandd/english/1297/articles/0141297.htm

10. FAO. “Bank Rakyat Indonesia – Unit Desa”. Website: http://www.fao.org/ag/ags/agsm/banks/banks/indones2.htm

11. MiFi Report. “Grama Vidiyal raises over USD 4 million of Equity Capital…” MiFi Report. June 17, 2009. Website: http://www.mifireport.com/2009/06/grama-vidiyal-raises-over-usd-4-million-of-equity-capital-the-first-equity-investment-in-india-in-2009/

12. Grameen Bank. “Grameen Bank Monthly Update in US$: June, 2009”. Grameen Bank. June 2009. Website: http://www.grameen-info.org/index.php?option=com_content&task=view&id=453&Itemid=527

13. Jed Emersen. “The Nature of Returns: A Social Capital Markets Inquiry into Elements of Investment and the Blended Value Proposition”. Social Enterprise Series No. 17. 2000. Website: www.blendedvalue.org/media/pdf-nature-of-returns.pdf

Vishal Raman explains the situation of Third World child malnutrition and discusses how efforts to combat it still have a long way to go.

The World Health Organisation (WHO) regards hunger as the gravest single threat to the world’s public health. This should come as no surprise to those who have read the 2008 Lancet Series on maternal and child undernutrition, which estimates that 3.5 million children under 5 years are dying annually due to hunger related causes (1-5). It is a sad fact that although these deaths are largely preventable, nutrition still remains a severely neglected issue on the global health agenda. Norman Borlaug once described the existence of a “forgotten world – where people live in poverty, with hunger as a constant companion and fear of famine as a continual menace.” At this defining moment in the fight for social justice these children must not be forgotten and this issue cannot be ignored.

It is thought that 178 million children under 5 years are stunted (see box) and 80% of them live in just 20 countries predominantly located in south-central Asia and sub-Saharan Africa (1). India alone is home to 61 million, which is 51% of all Indian children under 5 years. Globally, 112 million children are underweight and 55 million are wasted, of whom 19 million suffer from severe acute malnutrition (SAM). The sheer magnitude of this crisis must not be underestimated. Maternal and child undernutrition is the underlying cause of 35% of the disease burden in children of this age group and 11% of the total global disability adjusted life years (DALYs) (1). It is now clear that a critical window exists in a child’s life, from conception to 2 years of age, where inadequate nutrition causes irreparable damage and leads to serious long-term consequences (2). Stunting and severe wasting in the first two years of life have been shown to permanently impair an individual’s growth and cognitive development. They are associated with reduced educational achievements, increased risk of chronic disease and diminished economic potential in later life (2). In fact, an excellent predictor of future capital is a child’s height-for-age at 2 years of age. Childhood undernutrition can have significant repercussions for the health of coming generations as well as the future economic capacity of these burdened nations. Therefore, all those involved in the fight against hunger should recognise that investment in this crucial period of a child’s life is vital. It will have immeasurable benefits for that individual as well as their country.

WHO Defined Indices for Assessing a Child’s Nutritional Status

Stunting – Defined as a height-for-age measurement 2 standard deviations (sd) below the reference median and it primarily reflects chronic undernutrition.

Wasting – Defined as a weight-for-height measurement 2sd below the reference median and it primarily reflects acute malnutrition.

Severe Acute Malnutrition – Defined as a weight-for-height measurement 3sd below the reference median and it is used to determine those in need of urgent life-saving therapy.

Underweight – Defined as a weight-for-age measurement 2sd below the reference median and it is a result of acute and/or chronic malnutrition

Importantly, a number of highly effective interventions exist to improve child nutritional status (3). Those with the strongest evidence base include educational campaigns that promote breastfeeding and appropriate complementary feeding, provision of foodstuffs for food-insecure populations, micronutrient supplementation and the treatment of SAM. Of the micronutrient interventions, vitamin A and zinc supplementation have had the greatest impact with universal salt iodisation also showing promise. The management of SAM has recently been revolutionised with the success of home-based treatment and ready-to-use therapeutic foods (6). This has reduced in-patient admission times and so enabled greater numbers to be treated. Universal coverage with the full package of proven therapies could reduce child mortality by one-quarter and the prevalence of stunting by one-third. Sadly, in the 20 countries with the highest burden of undernutrition a significant number of these established interventions are simply not being adequately employed (4). Only 5 of these states (Afghanistan, Bangladesh, India, Madagascar and Nigeria) report nationwide implementation of behaviour change communications to improve complementary feeding. Similarly, Indonesia and South Africa are the only countries from this group where zinc fortification has been introduced at a national level. Thus, it is essential that adequate resources be directed at specifically implementing these proven interventions in the areas where they are most required and on the scale that is necessary for substantial results to be achieved.

When designing plans to address malnutrition great emphasis should be placed on empowering local people and strengthening regional facilities. It is clear to see why when one looks at the success organisation such as Partners In Health have had by investing in community-centred care (7). They train local health workers who act as an invaluable link between health clinics and local communities by serving as counsellors, educators, treatment providers and advocates experienced in local needs. This means that the strain on both patients and local health systems is drastically reduced. Also, the health industry and economy in these areas is greatly strengthened as a result. If change is generated at this kind of grassroots level it will be powerful, meaningful and most importantly sustainable.

Unfortunately, despite the seriousness of this issue there is still an appalling shortage of international investment in improving nutritional outcomes in poor countries. It is estimated that total aid for basic nutrition in low and middle-income countries from 2000-05 was in the order of $250 to 300 million annually. In contrast, HIV/AIDS, which in fact causes the loss of less DALYs than child undernutrition does, received $2.2 billion a year in foreign aid during 2000-02 (5). A major reallocation of international donations is required; funds dedicated to dealing with paediatric malnutrition need to be greatly increased and suitably targeted.

The following words from Martin Luther King’s Nobel lecture are particularly pertinent at this time (8). “It will be a fierce struggle, but we must not be afraid to pursue the remedy no matter how formidable the task – for why should there be hunger and privation in any land, in any city, at any table when man has the resources and the scientific know-how to provide all mankind with the basic necessities of life?” World leaders and the international community as a whole must acknowledge the fierce urgency and significance of the fight against childhood hunger. This challenge has to be met with unequivocal political support and substantial financial assistance. A genuine collaborative effort between all those involved is imperative. Only then can there really be hope for every hungry child.

Vishal Raman is a 5th year medical student at Oriel College, Oxford. vishal.venkatraman@oriel.ox.ac.ukReferences

1. Black R, Allen L, Bhutta Z, et al, for the Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008; 371: 243–60.

2. Victora CG, Adair L, Fall C, et al, for the Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: consequences for adult health and human capital. Lancet 2008; 371: 340–57.

3. Bhutta ZA, Ahmad T, Black RE, et al, for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. Lancet 2008; 371: 417–40

4. Bryce J, Coitinho D, Darton-Hill I, et al, for the Maternal and Child Undernutrition. Maternal and child undernutrition: effective action at national level. Lancet 2008; 371: 510–26.

5. Morris SS, Cogil B, Uauy R, for the Maternal and Child Undernutrition Study Group. Effective international action against undernutrition: why has it proven so difficult and what can be done to accelerate progress? Lancet 2008; 371: 608-21.

6. Ciliberto MA, Sandige H, Ndekha MJ, et al. Comparison of home based therapy with ready-to-use therapeutic food with standard therapy in the treatment of malnourished Malawian children: a controlled, clinical effectiveness trial. Am J Clin Nutr 2005: 81: 864–70.

7. Pih.org [homepage on the Internet]. Partners In Health. Issues We Face, Community Health Workers. Available from: http://www.pih.org/issues/delivery.html

8. Nobelprize.org [homepage on the Internet]. Martin Luther King Jr. The Nobel Peace Prize 1964, Nobel Lecture. Dec 1964. Available from: http://nobelprize.org/nobel_prizes/peace/laureates/1964/king-lecture.html

Quratulain Fatima Masood, Muhammad Zeshan Ali and Jawad Mahmood Qureshi write about the tobacco farming industry looking at its global extent, related health and economic problems, and suggest ways in which the global community can combat this industry.

Globally, the tobacco industry is one of the most lucrative. It forms a vicious cycle involving the farmer, the manufacturer, the state and the unfortunate consumer.

As a result, the tobacco pandemic has struck developing countries like a brush fire. The personal and social distress, not to mention the associated economic losses, in poverty stricken countries of this pandemic are largely sustained by a self reinforcing cycle of poverty, tobacco farming and illness.

This article aims to question the how an industry, with such widely known damaging effects, can be allowed to continue to wreck havoc across the world, without any checks being imposed. The answer and the solution to the problem lies in analyzing who benefits the most from its ongoing existence. (more…)

 Suvash Shrestha discusses how the causal relationship between poor health and poverty runs in both directions

About 1 billion people globally live in extreme poverty on an income of less than $1 a day, of whom 70 million live in Asia and the Pacific (1). These regions are also struggling hard to provide health facilities and services and there are high rates of mortality from conditions which could easily be prevented or treated. It is not hard to see the strong correlation between economic and health status. And since poverty breeds poor health which keeps people poor, it is a very serious and emergency condition that should receive global attention.

Both at the individual and national levels, poverty is no doubt the biggest hurdle we have to overcome to achieve satisfactory health status. There are stark disparities in health expenditure between rich and poor countries. In Nepal, the per capita total expenditure on health in 2004 was less than 0.2 % of per capita expenditure in the USA (2). 

 At the individual level

At the individual level poor people have a difficult time living hand to mouth. They have to work in adverse conditions like brick kilns and factories without any protective measures, exposing them to occupational health hazards. To add more insult, poor people can rarely afford adequate nutrition leading to undernourishment which increases their vulnerability to disease. Owing to poverty, people can not afford to maintain proper sanitation and hygiene which again predispose them to various diseases.

In addition, limited access to education leaves the poor completely oblivious of the disease conditions, their prevention and treatment. They still live with many superstitions and myths which may result in harmful health practices. Many cannot afford the luxury of TV and radios, and in Nepal where the adult literacy rate is only 48.6% (2), most poor people cannot read newspapers and magazines. This restricts access to information about health which is disseminated via the media.

Due to extreme work pressure and the need to earn few more rupees to support their family, poor people rarely have time to attend health promotion programs in their community such as training on sanitation, proper nutrition, family planning, vaccination and free health camps. Annually, the government of Nepal has been running free programs like pulse polio immunization program and vitamin A capsule distribution. But the poor, having to work from dawn to dusk, don’t get time to get their children vaccinated. So, from every way, they miss the health information and they have no idea what facilities are available for them even if there are any.

What is more, even when they fall sick, the poor have many barriers to accessing health care. The biggest of all is the financial one. The treatment services are often too expensive for them, and at centers where services are free, limited funding can mean that the range of services offered is very low. In some areas, there are fee waiver and exemption schemes to help the poor but in practice these have been found to benefit better off groups rather than the most needy. Because health services are centered in the urban areas, they have to travel a long distance to access health services, and even the cost of transport can form a major barrier.. The time spent seeking medical care also means a loss of income,a further deterrent from doing so. Thus, service availability, accessibility, prices and quality greatly affect health outcomes for the poor.

An associated problem is that the poor may not care for minor ailments. Due to a lack of knowledge and poor access to health services, they may not to get a check up until the symptoms become severe, usually at advanced stages of disease.. This makes treatment difficult, more costly and longer. Low incomes are also associated with reduced compliance with treatment regimes, since patients who have begun to recover may chose to spend money on other family needs rather than on costly medicines. thus never receiving complete treatment. This is especially true for diseases like tuberculosis. Here the problem was so grave that even when the Nepalese government provided anti-tubercular drugs for free, the poor would collect the drugs from the hospital and sell them to local pharmacists at a lower price to earn some money for their family. Thanks to the Directly Observed Treatment Short courses (DOTS), compliance with treatment has improved, but the constraints of poverty have not changed.

At the national level

At the national level, government has not been able to assure health facilities to all. If we look at the national budget distribution in Nepal, the health sector received only 9.23% of total allocations this year, as little as US $191 milion. (3) The figure clearly depicts how serious the condition is.

In poor countries, the number as well as the quality of health centers is unsatisfactory. Nepal has only 0.21 doctors per 1000 people and only 2 hospital beds per 10,000 people compared to 2.56 doctors per 1000 people and 33 beds per 10,000 people in the USA (2). Even these figures do not capture the gravity of the situation in the rural areas, since most hospitals and health services are centered in the urban centres. In remote areas, where most of the neediest live, there are only some health posts and sub-health posts which are also not sufficient and are barely equipped.

Even the so-called big centres are very ill-equipped without even an X-ray and or a US machine, let along CT and MRI scanners. In places where this equipment is available; it often remains out of working order due to poor maintenance, or unused due to a lack of trained staff. Staffing is another big problem; in Nepal, only 20% of rural physician posts are filled in comparison with 96% in urban areas (1). This is most likely because the government has failed to provide adequate salaries and other facilities. This is also the reason why most health professionals are flying away to the developed countries in search of better incomes and a better quality of life.

On account of poverty, government has failed to promote any research in the field of health. New discoveries are far-fetched things, and even the basic study of health status and disease prevalence are lagging due to very little funding. There are no proper training programs for health workers. Government has not been able to launch regular health campaigns and screening programs, and those which have been initiated are yet to reach all corners of the country. Even the donor agencies struggle to reach the needy ones due to poor transportation facilities.

The search for solutions

The definite solution lies in finding new resources and using the available ones to the maximum. Realizing that resources are always limited, we should be able to make the most out of them. The first step should be to prioritize our needs. For this proper studies should be done at the grassroots level to ensure that plans formulated are appropriate for national social, cultural and economic status.

Resources should be reallocated in favor of poorer geographic areas, and to the lower tiers of service delivery. Investments should be focused in health conditions that disproportionately affect the poor like TB, malaria, HIV, infant and child mortality, maternal ill health and malnutrition.

Curative treatment is expensive, so we should focus on the preventive aspects. We can educate village health workers about proper hygiene and sanitary practices, nutrition, the importance of vaccination, family planning and other relevant topics. Since they are from the community itself, they could deliver this information directly to our target groups and could thus be very effective.

Large health centers are too expensive to establish and maintain, as they require more manpower, resources and equipment. Instead we could run community based small health centers which would be cost-effective and easier to set up in remote areas. Regular mobile health camps could also be a very effective solution.

Since many developed countries are willing to help, the government should welcome them and provide a politically stable environment in which to work.

Conclusion

The causal relationship between poverty and health runs in both directions; poverty breeds ill health and ill health keeps people poor. It is therefore vital to break this vicious cycle for a healthy population and a prosperous nation. After all, a healthy population is more economically productive than one that is not, allowing goals in other sectors to be achieved faster.

Suvash Shrestha
Kathmandu Medical College
Kathmandu
Nepal
suvashsht@gmail.com

(1) WHO, Fact sheets, Health, poverty and MDG, accessed October 25 2007, http://www.wpro.who.int/media_centre/fact_sheets/fs_20050621.html

(2) WHO, Core health indicators; accessed October 25, 2007, http://www.who.int/whosis/database/core/core_select_process.cf

(3) National Budget, accessed October 25 2007, available from http://www.mof.gov.np/publication/speech/2007/pdf/BudgetSpeech_english.pdf