Society Sans Medicine
Poverty as a Disease
Daya Ram Varma
[The Late Dr Daya Varma was born in a peasant family in a village called Narion, in UP. Starting from a one room pathshala, in a mud house with a dirt floor, he went on to complete his secondary, post- secondary and graduate education. He walked to school every day for eight kilometres and sometimes was seen taking a ride back on a bullock cart. He was known as the boy who did his homework on the cart. His father had lost the little land he had to money lenders, but taught in a primary school to pay back the money lenders. His father carried 40 kg of grains on his head and walked 30 km to deliver to Daya, when he was going to college. Daya went on to study at King George Medical College in Lucknow for his MBBS. On his part, Daya worked as a servant in households and slept in a space donated by a fellow student outside his hostel room. In 1959 Daya obtained a scholarship to McGill University, known as the Harvard of Canada and he finished a PhD in a record time of less than two years. It remains a record in McGill annals. He went on to publish over 225 scientific papers in reputable journals worldwide. He retired as a Professor Emeritus, some ten years ago. But, this is not just about Daya as the brilliant academic, although he had published over 200 articles in scientific journals all over the world. Daya was a founding leader of the Indian Peoples' Association in North America, along with the late Hari Sharma and others. Daya was intrinsically a scientist, humanist, socialist and a deep believer that Poverty is not simply a symptom of a non-egalitarian society, but an actual disease form that manifested itself through a transmission of the health condition from generation to generation. Below is the last article he wrote and he completed it only a few weeks before he passed on. —Rana Bose]
Roy Porter titled his book "The Greatest Benefit to Mankind: A Medical History of Humanity"; it is an excellent book but it raises the question—is medicine the greatest benefit to humanity? It is true that medicine made gigantic progress in the second half of the twentieth century. Some of the dreaded epidemics like smallpox, plague, cholera have been tamed. Polio is on the verge of being conquered. Antibiotics have dramatically reduced mortality from infectious diseases. Longevity has significantly increased and maternal and infant morality as well as death from tuberculosis dramatically declined by the end of the nineteenth century much before the discovery of antibiotics. However, medicine has been of limited benefit. Many people never get sick enough to require medicine.
On the other hand, poverty has killed more people than all diseases combined. Indeed famines alone have taken a greater toll of the poor than the worst pestilence in history. Poverty is the number one killer in the world today, outranking smoking as the leading cause of death. More than a billion people live on less than $1 per day. Each year, 9.7 million children worldwide die before their filth birthday, and almost all of them are in poor families. No medicine can cure poverty and no medical researcher can find a solution to this greatest scourge of all times—poverty.
Non-availability of food is the extreme expression of poverty. During the Stone Age some 200,000 years ago, the sole occupation of Homo sapiens was the search for food and shelter. The success was limited, longevity was approximately 30 years and the population increase was very slow. India's population, for example, remained stationary at approximately 100 million from 300 BC to AD 1600. Neither the Vedas nor Ayurveda and Siddha helped increase the population. The increase in India’s population to approximately 255 million by 1871 and to approximately 389 million by 1941 was due to a decrease in mortality rather than an increase in birth rate, which in turn was a consequence of increase in means of sustenance during the period of Mughal and British rule rather than improved healthcare. This has been the case despite several famines during British colonial rule, the last one being the 1943 Bengal famine. Amanya Sen (1982) argues that famines are not caused by overall shortage of food, which clearly implies that the victims of famines are the poor. Surprisingly Arnold J Toynbee (1946) does not consider poverty in his presentation of the genesis and breakdown of civilisations. Since independence in 1947, India's population has been steadily increasing. There are more than one billion Indians now with a concomitant increase in the number of the poor.
Given the importance of poverty in human misery, many philosophers, political economists, and sociologists has dwelt on various dimensions of poverty. Adam Smith (1776) makes repeated references to the prevalence and causes of poverty in "The Wealth of Nations". In his 1844 classic "The Condition of the Working Class in England", Friedrich Engels gives a vivid description of poverty in rapidly industrialising Britain. Karl Marx does not deal specifically with poverty (other than in philosophy) but does talk about pauperisation; he says "they (capitalists) transform his (worker's) lifetime into working time and drag his wife and child beneath the wheels of the juggernaut of capital..... Accumulation of wealth at one pole is, therefore at the same time accumulation of misery, the torment of labour, slavery, ignorance, brutalization and moral degradation at opposite pole, i.e. on the side of the class that produces its own product as capital." Marx (1853) condemned the colonial neglect of the "Department of Public Works", which was the lifeline of Egypt, Mesopotamia, Persia, India et cetera. About India, Marx wrote: "Now, the British in East India accepted from their predecessors the department of finance and of war, but they have neglected entirely that of public works. Hence the deterioration of agriculture...." Philosopher John Stuart Mill (1879) raised the question of poverty in England, he recognised that : "The reward, instead of being proportioned to the labour and abstinence of the individual, is almost in inverse ratio to it those who receive the least, labour and abstain the most." Sir Edwin Chadwick advocated a drastic overhaul of the Old Poor Law and its replacement by the New Poor Law, which required regulated, centralised, government welfare of the poor, to be managed by salaried officers controlled by a central board. There are numerous books on the condition of native and black Americans. Anna Rochester (1940) deals with poverty of farmers in America, not too different from the crisis faced by the farmers of India. Amartya Sen (1982) also deals with poverty and famines. A running theme of great litterateurs like Emile Zola, John Steinbeck, Charles Dickens, Munshi Premchand and many others was poverty.
Surprisingly there is a greater demand for universal healthcare than for universal eradication of poverty. In his provocative book "Revolution from Above", Sociologist Dipankar Gupta (2013) identifies "health" and "education" as the cardinal needs of the Indian society. However, poverty and health cannot coexist and education is a luxury for the poor while suffereing is a constant companion.
There are many definitions of disease; these definitions are not identical but not substantially different from one another. The American Professor Rein examines poverty from the perspectives of the non-poor and writes: "People must not be allowed to become so poor that they offend or are hurtful to society." According to Mario Bunge (2013), who writes extensively on philosophy of medicine, "what is common to all diseases is that they threaten life".... healthy organ is "one that discharges all" essential (vital) functions of an organism while "disease" is a "disruption of one or more such functions"; poverty does all these.
The 1978 International Conference on Primary Health Care, held at Alma-Ata, USSR (present Kazakhstan) had declared that health "is a state of complete physical, mental, and social well-being (emphasis added) and not merely the absence of disease or infirmity". The Declaration does not directly spell out its dimension of "social well-being" but implies eradication of poverty as an obligatory pre-condition for a healthy society. Poverty, like a disease, is invariably associated with suffering and an increase in morbidity and mortality.
Poverty is visible and a world-wide phenomenon. No skill is needed to diagnose poverty. Yet, considerable scholarship has been drawn in defining poverty and none seem fully accurate. Poverty is an object of scorn by non-poor all over the world. In India it is not unusual to find an affluent family at a picnic or a railway station shout at a little emaciated boy or girl, in anticipation of crumbs, for disturbing them during their sumptuous meal.
The British sociologist Peter Townsend (1970) has edited a book titled "The Concept of Poverty"; there are thirty-four contributors, none from Asia, Africa and Latin America. The book provides multiple definitions, all relevant but none complete. It is difficult to sum up this 260-page book, but the definition by Rowntree (1941) based on a survey of York (UK) seems most relevant to conditions in India; he writes "primary poverty line represented the minimum sum on which physical efficiency could be maintained".
Indian economist Utsa Patnaik (2007) contends that "at least three-quarters of rural and over two-fifths of urban population" are poor; her main criteria of judging poverty seems to be caloric intake and according to the data presented by her, approximately 20 percent of the population consumes less than 1800 calories. However, the two main determinants of caloric requirement are physical activity and age. It is reasonable to assume that the poor perform greater physical activity than the rich and therefore need more than 1800 calories.
While Patnaik relates caloric consumption to income, it would have been even more useful if she related it to the profession. There are regional differences in poverty with Punjab, Haryana and Kerala being better off than other provinces. Dube (1955) dwells on the distribution of poverty; according to him, in a typical village, untouchables account for nearly 27 percent, who approximately account for all the poor; they usually own no or little arable land.
The Economic & Political Weekly editorialised (2010) that "the rapid economic growth of the past quarter century" has created "two Indias", one of which "mainly rural but also the underbelly of the cities—has been left behind because it has neither assets nor skills. The poor also have to cope with a collapse in public services." That there are two "Indias" is obvious but one cannot be sure if such a division of India is due to "rapid economic growth" or lack of "skill" rather than social policies behind such rapid growth. Lu and Montes argue that rapid growth in China and Vietnam has resulted in "higher household incomes, greater access to consumer goods, improvement in diet, and rising living standards, as well as sharp reduction in poverty".
Consistent with the theme of this article it would be appropriate to consider poverty a state which compels people to eat less than they need, live in unsanitary quarters or on streets, work longer hours and harder than appropriate, resort to child labour, poor schooling, and encounter physical and verbal insults from the rich and the organs of the state such as the police, and so on. Income inequality is an important reflection of the state of economy but cannot be a measure of poverty. The income of one of the Ambanis must be many times more than that of the Vice-Chancellor of any university of India but the latter are not poor. At the same time poverty has a social context. A poor person in the USA is unlikely to match a poor person in India but still lives a life of deprivation and bears the consequences of poverty.
The book "Public Health and the Poverty of Reform: The South Asian Predicament" edited by Qadeer, Sen and Nayar (2001) elaborates on many aspects of health policies in South Asia; (unfortunately this 543-page book has no subject index, which suggests an unprofessional approach of the Publishers, Sage Publications). None of a total of thirty-three Chapters addresses the relationship between poverty and health. Whenever the term "poverty" appears it is only in relation to the atrocious policies of the World Bank and International Monetary Fund and not to the state of the civil society.
There are two aspects to the relationship between poverty and healih. One is the infringement on the quality of life of the poor in the absence of any medically recognised disease. The other is the greater vulnerability of the poor than of the non-poor to diseases.
Poverty is a state of suffering; suffering, whatever be its cause, is a disease. The poor, especially poor women look older than their age except when they are depicted in Bollywood films. Every child birth expedites the aging process of poor women. In pour households, women have to work as labourer in addition to the routine work at home. Most affluent households in an Indian metropolis prefer to employ young women; they are in plentiful supply from Jharkhand, Nepal, tribal areas and so on. Aside from social deprivation, these bonded employees are mistreated in many households. Indian newspapers occasionally report cases of extreme abuse but in all likelihood, majority of domestic employees are underpaid and over-abused.
The prime and distinguishing feature of Hinduism is the caste system. Almost all children, women and men of the low caste are at the lowest rank in income. Many perform degrading work as scavengers. Poor are more likely than the non-poor to die during natural disasters such as floods; for example majority of the victims of tsunami of 2004 were poor as were the victims of hurricane Katrina in New Orleans. The list is long and the problem so massive in India that majority of non-poor have become insensitive to the plight of the poor and many believe in the Hindu doctrine that they must have done something wrong in their previous life.
Anaemia is common among the poor due to inadequate nutrition and in many cases due to hookworm infestation.
Social status also plays a critical role in epidemics. All known epidemics such as cholera, plague and smallpox preferentially kill the poor. For example, the plague epidemics in India between 1903-1921 killed nearly ten million people; the death rate per 100,000 was 53.7 for low caste Hindus, 20.7 for Brahmans and 4.6 for Parsees.
In most cultures, there existed a kind of harmonious relationship between people and nature; colonisation and industrialisation disturbed this relationship. The native population of the Americas was virtually wiped out following its discovery by Columbus; the destiny of natives of Australia, Canada and New Zealand was no different. Africa still has to undo ihe damage caused by colonisation. The formal abolition of slavery in America has yet to allow the Afro-American people to be fully integrated in the society. Natives and black people make up the bulk of the poor.
The struggle to eradicate poverty is as old as civilisation itself. This struggle has taken various forms such as slave revolts, fight for 8-hour working day, minimum wages, paid vacations, old age pension, the right to unionise, universal franchise and so on. Almost all these struggles drew some support from or were initiated by non-poor and reformers and social activists. Despite these struggles, poverty continues to prevail. It would thus seem that the system of governance rather than piecemeal efforts need be changed to eradicate poverty; it is not within the domain of healthcare.
Karl Marx and his associate Friedrich Engels had a vision of a society where poverty would not exist and freedom for one would be freedom for all. The Bolshevik revolution of 1917 accomplished some success in eradicating poverty but the sudden collapse of Soviet Union without the slightest protest by the masses implies that the state and economic structure was not to the satisfaction of the majority of the people. On the other hand, a similarly proclaimed state in Cuba seems to be doing better.
Sufficient resources and technical know-how exists to be able to eradicate poverty in most countries. Only Scandinavia seems to have greatly solved the question of poverty amongst capitalist societies. Abject poverty does not exist in Cuba and the government, unlike the Soviet Union and Eastern Europe of yesteryears, is not unpopular but dissatisfaction is obvious.
Vol. 48, No. 52, Jul 3 - 9, 2016