Don't Blame the Poor for Diseases of Poverty

Diabetes is often referred to as a disease of the relatively affluent because it can be caused by some of the habits that are common in better off, urbanized areas. It can be associated with foods that have high levels of sugar, often highly processed foods, along with a sedentary lifestyle.

However, it can also be a disease of the very poor, those who have little choice over which staple food they rely on for almost all of their nutritional needs. In Tanzania and Kenya, for example, many people rely on staples that are high in starch, and little else. Maize, white rice, white bread and a small number of other foods can make up the bulk of the daily diet of most people.

An article in the New York Times may give the impression that there are lots of Africans suffering from diseases of affluence. I'm not sure why this article is about such a small sector of the East African population, though it may well be true that there are more wealthy people now than before. But diabetes is far more common than affluence.

I accept that the article is quite clearly about the African middle class, but the association of diabetes with increasing wealth is disingenuous. There are people suffering from diabetes who are neither affluent, urbanized nor sedentary. Are we supposed to see people in such circumstances as being responsible for their suffering from the disease?

The same article mentions lung cancer. One of the biggest killers in developing countries is acute respiratory conditions. This is not because most people smoke cigarettes, live close to a polluting but highly lucrative (for them) industry, live in a city or do anything else that relates to affluence. It is because they are exposed to living conditions that render them susceptible to serious lung problems. It is also because health facilities are poor and inaccessible.

In fact, if any generalization can be made about diarrhea, water-borne diseases in general, nutritional deficiencies and acute respiratory conditions, it is that they affect more babies and infants than adults. In adults, respiratory conditions affect women more than men. Also women and children are far more likely to be living in poverty than men.

The majority of people do not have access to private transport, some don't even have access to public transport. Most do not work in offices, most don't even have formal jobs of any kind. Most still have to walk to health facilities and social services, or even do without them. There are, presumably, risk factors for cancer, heart disease and strokes that relate to poverty as well as to affluence.

Urbanization has been a trend for a long time but it is unlikely to contribute that much to diseases of affluence in East Africa. Urban dwelling poor people are probably even more deprived than rural dwelling poor people and they face additional health hazards that those in rural areas don't face. These hazards include air quality, pollution, road traffic accidents, occupational hazards, violence and others.

I don't wish to belittle common health conditions, regardless of who suffers from them. But it is poor people who need better and more accessible health services, whether urban or rural dwelling. And many people are suffering from preventable and curable conditions that relate to their diet, their environment, their economic circumstances and adverse social conditions, not just from their 'lifestyle'.

An article about health in Zimbabwe illustrates the point: "70% of diseases and deaths in the country, caused by malnutrition, diarrhea, malaria and pregnancy-related complications, are preventable." Similar figures can be found for Kenya and Tanzania. It's a popular game in the press, in development and in politics to deflect attention from the problems people face that are beyond their control and to concentrate on issues that are, ostensibly, a matter of individual responsibility. There is a lot of public health work that needs to be done. Poor countries are not 'like' rich countries when it comes to health.

Towards a Vaccine for Stupidity?

In an article entitled 'HIV vaccine trial results raise more questions', the recent, much reported vaccine trial results are, it is suggested, open to many interpretations. But whether a HIV vaccine is still a distant hope or already close at hand, I would argue, is not what we should be concentrating on.

Some of the reasons why many people are becoming infected with HIV and other sexually transmitted infections could be that they do not have access to good sex education or family planning, they do not use condoms, they are not always in a position to choose whether to have sex, when, with whom, how often and under what circumstances. True, many people know that HIV is a threat but there are so many threats that people just get on with their lives, HIV positive or otherwise. But this only partly explains high HIV prevalence.

Health, education and other social services are pretty much inaccessible to the majority of Kenyans and the majority of people in all developing countries. People are, effectively, denied their rights to a decent standard of living. They live in poverty and suffer from the consequences of poverty. People experience all manner of illnesses that are easily and cheaply controlled and many die unnecessarily, often at a very young age.

HIV is just one of numerous diseases that threatens the lives of people in developing countries, just one chronic disease that further impoverishes people who are already impoverished. The fact that billions of dollars are spent on finding HIV vaccines and other drugs does not make people more scared of it. Sometimes it even makes people think that a vaccine or cure is probably just around the corner.

Cures and vaccines are likely to be some way off; affordable cures and vaccines are quite another story. But, as we have seen over a period of more than two decades, people certainly don't modify their behaviour in the way that health and other professionals suggest they should. This is as true of developed countries as it is of developing countries, as true of HIV as it is of obesity, dangerous driving, drinking, various kinds of exploitation, corruption, crime and drug use.

What should we be concentrating on? Instead of putting such copious amounts of HIV funding into treating people already infected, a lot more money and effort needs to be put into preventing new infections from occurring. Much of the money currently spent on treatment and care of HIV positive people goes into intellectual property. In other words, there is existing legislation that would allow the costs to be cut, substantially, without reducing current levels of treatment and care.

As to what measures could lead to preventing HIV infections, a lot of research is needed, research that must be carried out without the biases of power politics, pseudo moral posturing, fashion and pure greed. By now, we know a lot about what doesn't work and we need to be frank in admitting that. But perhaps we also have some insights now; perhaps the promise of greater lifetime opportunities could lead to people taking fewer risks and making better decisions that relate to their health. The promise of a better standard of living, education, employment, habitation, health and social services could achieve a lot more than the patronising rubbish that has, up to now, passed as HIV prevention programming.

Most people in the world live in poverty and are denied their basic rights. They live in the majority world. Rather than putting so much of the world's aid money into a cure for one disease, some of this money could be used to change the way the minority world treats the majority of people. Indeed, much 'aid money' is used for all sorts of things aside from aid. It's used for 'technical assistance' (which usually means paying rich Western consultants and experts a little too handsomely for their advice), dumping surpluses, subsidizing the industries of rich countries, creating markets for consumer goods, etc.

Kenya and other countries not far from here are used and have long been used, as sources of cheap raw materials and labour. Much of the country's land and resources are given over to producing raw materials for the minority world. Much of its workforce receives very low pay, working in conditions that would be illegal in the West, to produce raw materials and cheap goods for the West.

Like all other diseases, HIV has a context, an environment. Countries with high HIV prevalence also have high rates of other diseases and other health and social problems. They suffer from extreme levels of deprivation and they are usually heavily exploited by rich and powerful countries. While a vaccine or cure for HIV may be a long way off, vaccines and cures for other diseases are not just available but cheap, for example treatment for intestinal parasites, which affect billions of people.

Some of the biggest killers are things like water borne diseases and acute respiratory conditions. Perhaps as much as half of the illnesses and premature deaths in developing countries could be avoided by provision of clean water and sanitation and decent places to live. That is not beyond human ingenuity, it just doesn't seem to get the same attention as a possible vaccine for one disease that affects far fewer people.

Clarification:

In a recent posting I argued that "it is not poor people in developing countries who contribute the most to global warming and environmental destruction, it is rich people in rich countries." A friend complemented me on this argument but I had to admit that it comes from an article entitled 'The Population Myth', by George Monbiot. Indeed, many of my views on development are influenced by the writings of Dr Monbiot and it was not my intention to claim credit for his work.