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.

Prevention Needs to Consist of More than Good Intentions

To continue a theme that crops up regularly in this blog, an article on AllAfrica.com argues that Kenya needs to invest more in prevention campaigns than curative ones. True enough, but this article is about non-communicable conditions, such as hypertension, diabetes, mental illnesses, asthma and cancer. Health should start with prevention, whether that involves preventing communicable conditions, non-communicable conditions or even accidents such as road traffic accidents, industrial and agricultural accidents or injury and death from criminal acts.

However, realising that prevention is important is one thing, actually doing something about it is another. Take road traffic accidents (RTA), for example. All sorts of shenanigans have been put in place here recently, ostensibly to reduce RTAs. There are police checks and the rest, but what do the police do, exactly? Well, it's no mystery, they take a bribe and wave the driver on. There could be 22 people in a vehicle licensed for 14, bald tires, faulty brakes, out of date insurance or whatever, but as long as the police get their money, no further questions are asked.

In a country where health spending and health infrastructure has been reduced and continues to be reduced since the early 1980s, what exactly are health professionals supposed to do about all these conditions, communicable and non-communicable? The fact that prevention is better and cheaper than cure is irrelevant when there is bugger all money, anyway. But, even where prevention is even felt to be worth the effort, such as with HIV/Aids, are the figures for HIV transmission falling? Certainly not.

There is plenty of talk about preventing HIV but only 30% of HIV funding is allocated to HIV prevention. Most of that (which is probably nowhere near 30% of funding in reality) goes into a lot of mindless bullshit cobbled together by bigoted donors who don't give a damn about whether HIV transmission is really reduced as long as no one offends against their high minded but ultimately self serving interpretations of Christian morality. And it usually is Christian morality.

A report by a Nairobi based institution has come up with some alarming but unsurprising figures on teenagers knowledge of sex and their sexual behaviour. A large percentage of teenagers are having sex but they know little or nothing about safe sex. Unsurprising because they have been taught little or nothing about safe sex. Where has all the tens of millions of dollars intended for HIV prevention gone? It is has gone into not teaching teenagers about safe sex. I don't know how much money can be spent on the non achievement of something; that is in serious need of investigation. But the money is gone and the knowledge is nowhere to be found.

The report goes on to say that 40% of girls and 50% of boys have sex before the are 19, they believe all sorts of rubbish about sex, they fear pregnancy more than HIV, sex education is not taught in most schools, contraception is usually not mentioned (for fear of horrifying donors, politicians and church leaders, who are very sensitive people), half of the girls in a survey had exchanged sex for money, gifts or cash and 47% of the teenagers surveyed either had a child, were pregnant or had undergone an abortion. A separate study finds that 5.5 million girls between 15 and 19 give birth annually in Kenya, that's one eighth of the entire population!

If the calls for investment in preventing disease were to lead to improvements in very basic goods, such as water, sanitation and infrastructure, basic living conditions, primary health, education, gender equality, legal reform and things like that, Kenya would eventually be a lot better off. But it seems more likely that if any money is provided to prevent diseases and improve health, it will be spent on following purely political, commercial and religious agenda. Once those have been attended to, there's rarely any money left for anything else.