Factors contributing to variations in health status

Introduction

“We are all poor here because we have no school and no health centre. If a woman has a difficult delivery, a traditional cloth is tied between two sticks and we carry her for seven kilometres to the health centre. You know how long ittakes to walk like that? There is nobody who can help here, that’s why we are all poor here”.

• — Togo, 1996

Poverty

• Approximately 1.2 billion people in the world live in extreme poverty (less than one dollar per day). Poverty creates ill-health because it forces people to live in environments that make them sick, without decent shelter, clean water or adequate sanitation.

The children sometimes get sick for no reason. Sometimes it is because of lack of food.We are poor. We have no money to buy or to feed ourselves…

• Lack of food is the most frequently mentioned want. Hunger and

malnutrition are seen as underlying causes of many diseases. They cause weakness and exhaustion, and make people more susceptible to infection’s. Many people say they eat only once a day and sometimes have nothing for days on end. The poorest people rely on what they can find growing wild or by catching fish and shellfish. In towns, hunger is less dramatic or obvious than it is in rural areas, but poor people in Jamaica say that it is even more prevalent there than in the countryside. A group of women in Nigeria report that they are so weakened by hunger that they do not have enough breast milk to feed their babies. In Ethiopia there are expressions like “burning hunger” and “fire of hunger”. Parents worry constantly about providing enough food for their children.

Conflict

Poverty

• Activity p183 5.4 An Understanding of Health and Human Development.

• Article ‘More young caught in poverty trap’

Conflict/War

Many suffer ill-health as a result of war andconflict. A middle-aged man from Bosnia says:“The rise in the number of people with heartcomplaints, high blood pressure and depression has become normal for us.There is not a person in Tombak who does not suffer from at least one of these illnesses. All of this has been brought on by povertyand war.” A woman from Glogova says:“We all sufferfrom two illnesses: high blood pressure and nerves.”

Conflict• One of the prerequisites for ehalth is pece. In times of conflict,

opportunities to achieve good health are minimal. Conflict contributes to the burden of disease in many ways, one of which is poverty. According to the World Bank, many of the worlds poorest countries are locked in a vicious circle where poverty causes conflict and conflict causes poverty. 8-% of the worlds 20 poorest countries have suffered a major civil war in the past 15 years. On average countries coming out of war face a 50% chance of relapsing in the first 5 years of peace.

• Conflict also places considerable strain on health systems which often struggle to meet the needs of the casualties associated with conflict. Many of these casualities are women and children. According to UNICEF, more than 2 millions children have died as a direct result of armed conflict over the last decade and at least 6 million have been permanently disabled or seriously injured. More than 1 million have been orphaned or separated from families.

Cultural Factors• Cultural beliefs and practices can impact on health and

development. In many developing countries women have very low status and are valued only for their role in child rearing and domestic duties.

• Boys are often given priority over girls in educational opportunities and there are higher rates of female illiteracy.

• Females usually eat last and eat the least amount of food and infant boys are often breastfed longer than girls.

• More boys are immunised than girls. • Women are often viewed as the property of the husband and they

have little control over decisions. They are also more likelyy to suffer from violence. As a result, women’s health is likely to be worse than men’s.

Cultural Factors

• If a pregnant women is physically abused she and the foetus could be harmed and she many not be able to have any more children.

• Female genital cutting which can be a common customary act can cause serious vaginal and urinary infections resulting in sterility or death, complications during childbirth and mental health problems.

• Early marriage and childbirth is often the custom for many women. Childbirth is difficult for young mums because they are not physically developed. They are also more likely to give birth to low birth weight babies

Cultural Factors

• Complete Activity 1, Case Study and Activity 3 P185/186 Understanding Health and Human Development.

Women’s unequal access to health care is areflection of their lack of power in society. Voices ofthe Poor reports that women are typically excludedfrom decision-making in the community and at otherlevels. In Indonesia, poor women are said to have “noright to speak” at community gatherings:“If poorwomen protest, their voice will not be heard, or evenworse, they would be chastised for speaking in public”

Gender differences also affect men’s and women’sexperience of ill-health, and their access to healthservices. For example, women are more likely thanmen to suffer from exhaustion, while men may tend tohave drug or alcohol problems.Men aremore likely to access formal health care, while womentend to rely on traditional or other alternative healthservices, because they are cheaper and more sociallyacceptable.Men and women also tend to have different rolesin health care provision. Women are typically theproviders of health care, while men are morefrequently involved in making financial decisionsaround health care and in financing and transportingsick relatives to clinics and hospitals.

Literacy

• Globally almost 25% of the world’s population are not able to enjoy the benefits of being able to read or write. Literacy has a significant impact on health.

• Activity ‘Graph’ p187 and answer questions.• Read information p188 and answer questions

Access to Primary Health Care• Primary health care is one of the cheapest and most effective ways to address the major health

problems existing in the developing world. In 1977, the WHO identified primary health care as the means of achieving Health for All by year 2000. Its major focus is on health promotion and illness prevention but also includes elements of curative care and rehabilitation.

• In developing countries 50-90% of the population live in rural areas and have minimal access to health care facilities because they are essentially located in the cities. Primary health care overcomes this lack of access to health care by training village health workers or primary health care workers. These workers are often members of the local community. They can be trained for as little as .001% of the cost of training a doctor, yet they are able to treat diseases such as malaria and diarrhoea ,superficial wounds ,some eye diseases and skin diseases and are able to immunise children.

• They can provide valuable health education tomothers on issues such as child growth monitoring, nutrition, family planning, immunisation, breastfeeding, ort, and hygiene.

• Primary health care uses a community development approach where members of hte local community are consulted about their needs and are involved in all stages of the develpoment and implementation of a health care program. This ensure that health care and health promotion is delivered in a way that is culturally sensitive and meets the needs of the local community. In developing countries, typical components of a primary health care strategy are:

• Safe water and sanitation, food and nutrition, immunisaiton, curative care, essential drugs, health education, community development, maternal and child health.

Access to primary health care

• Question 1a and 2 p189 Understanding Health and Human Development.

Lack of access to Health Care• People stress, over and over again, that health care services are vital

to their survival and livelihood. However, the significance that the poor attach to health services is muted by their widespread disappointment – in some cases anger – at the bad quality of service and the difficulties of accessing care. These difficulties include the direct cost of doctors’ fees, medicines and bribes, and the indirect cost of transport to health services and time lost waiting for treatment. Abusive treatment by staff is a further disincentive to seeking care. Each of these is explored in more detail below. When formal health care services are unavailable, people turn to traditional medicine. In most cases, they say that they would rather be treated by modern health care providers, but often traditional services are all they can access or afford. As mentioned in part B, women are more likely than men to use traditional medicine.

Access to Health Care

Not every disabled person can afford the proceduresto qualify for disability payments.—Moldova, 1997Disability among the very poor is very common.Directly and indirectly, disability is often caused bypoverty. For example, a child may not be immunisedbecause its illiterate mother does not receiveinformation about a free vaccination programme, orsomeone may be permanently injured by doing adangerous job.The disability becomes disabling when there is noaccess to support, information and services. This canbe aggravated by discrimination and exclusion. FromBulgaria comes the report that disabled and blindpeople are considered “incapable of anything”. In manycountries, the authorities are said to obstruct disabledpeople’s access to disability allowance.Typically, the types of specialist health care thatdisabled people need do not exist. Where they areavailable, their high cost may effectively exclude poorpeople, or force them to interrupt treatment.

When women are sick, there is no one to look afterthem.When men are sick, they can be looked afterby women. — South Africa, 1998It is widely accepted that men are entitled toformal health care, and the resources needed to secureit, before women. Typically,women defer treatment oftheir own illnesses in order to get care for theirfamilies.Access to care may also be influenced by socialnorms affecting women’s mobility. In Pakistan, forexample, it is reported that women and children areunwilling to travel alone. In Balochistan, Pakistan,women say they are not “allowed” to travel to hospitalwithout their husbands. Similarly in Yemen, women donot go alone to health services unless they are nearby,and in any case, they must first seek approval fromtheir husbands or a male member of the community.Women’s social status and self-esteem may alsoaffect their access to health care.In another case in3 However,Voices of the Poor concludes that it is hard to generalise about these differences as gender roles and prioritiesare rapidly changing in many parts of the world.Pakistan, a woman said she did not want to go tohospital because, being illiterate, she felt unable todescribe her condition to hospital staff in ways thatthey would understand.

Health Care – Maternal and Child Health Services

• If women have access to health care and professional advice prior to and during pregnancy, birth and after delievery, dangers can be reduced for the mother and baby. The major causes of neonatal mortality in developing counties have been identified as pneumonia, congenital anomalies, prematurity, birth injuries, meningigtis, diarrhoea. All newborns need basic care, cleanliness, warmth, breastfeeding, eye care, immunisation. Babies are at increased risk due to bacterial infections caused by lack of hygiene at birth and during the newborn period. Women and infants delivered at home without a trained birth attendant and without precautions of hygiene are particularly at risk.

• Young women need advice about delaying pregnancy because of the increased. They need to be given information about the risks of early pregnancy and how to avoid them. The risk of death for young children increases by nearly 50% if the space between births is less than 2 years. With the birth of a new baby the health and growth of a child under two is at risk. It means breastfeeding of the older child ceases too soon, less time is spent making special food for that child and less attention is given than needed.

• Look at graph p 190 Understanding Health and Human Development.

Lack of Access to safe water and sanitation

• If two out of three children become ill and vomit it is due to the water; even though you can add chlorine, you’re never sure what you are drinking.

• —Women, Argentina

Safe Water

• Access to safe water means enough clean water is available. This means it is free of contamination from bacteria found in human and animal waste or faeces. Water should be boiled before drinking to kill any harmful germs.

Sanitation• In all regions, people describe their daily struggles to get water for human

use, but shortages are most widespread in Africa. Problems of distance, quantity, quality and safety of supply are mentioned, but also environmental hazards like flooding, siltation and pollution. For example, in Jamaica inputs into banana farming are said to contaminate local water supplies. Inadequate maintenance of wells, pipelines and bore-holes is also an issue. In Kwalala, Malawi, people report serious problems if bore-hole pumps break down in the rainy season. They know that taking water from the lake is risky, because it is contaminated with wastes from the highlands, but say that they have no choice. Lack of water for irrigation is identified as a major problem for rural communities, threatening livelihoods and household food security. Fetching water is not only time-consuming and hard work, but can cause injuries, especially to women. Indian women say they trek two kilometres to fetch water, and face dangers such as “boulders, slipping out of the rock joints… wild animals… wolves, and hyenas”.

Sanitation

• Just look how the kids are playing in the street with so much dirt.The water in the streets brings infections, and it is because of a lack of a sewage system…

• — A woman, Barrio las Pascuas, Bolivia

• Sanitation problems are acute in many communities, particularly in urban areas. In Bangladesh, for example, poor people point out the scarcity of latrines, and say that long queues often form outside toilets. Worries about health risks, particularly for children, and bad smells from open sewage canals, are particularly striking in the reports from Latin America. Sewage is said to “run openly in the roads”and endangers children playing in the street. The hazards of uncollected rubbish and waste are also mentioned frequently by poor people in urban Latin America. At Isla Trinitaria in Ecuador, a group of women describe how they live in cane houses on a pier above garbage-filled water.They talk of “a plague of flies” and “illnesses caused by pollution”. In some settlements at Nova California in Brazil, residents complain of foul-smelling garbage “causing all types of diseases affecting the community and especially children”. In Indonesia, several urban slums are in low-lying areas with poor drainage.The river brings in silt and garbage from the city. It floods during heavy rains, often causing skin and eye diseases, harvest failures

• and damage to houses.

When Children Waste and Die

• Poor people often identify ill-health with a particular season. In cold climates winter is the difficult time, while in tropical areas people fear the rainy season. In Ghana, people say “the rainy season is the time when children most waste and die”, and when diseases such as malaria, Guinea-worm, diarrhoea, skin and eye diseases and snakebites are rampant.

I look for a job every day. But some days I amashamed of going outside. Everybody will look at meand will know that I have no job and that is why I amroaming like a street dog….I am always sad, I do notspeak loud, I have headaches and I become nervous– from depression.—A Bulgarian man

Adequate and secure livelihoods are a centralconcern of poor people. Both in rural and urban areaspoor people have to work long hours to make endsmeet, often in dangerous jobs. They are driven intolivelihood activities that are not only dangerous butalso illegal and anti-social, including theft, drugdealing, sex work, child labour and trafficking.More and more poor people, particularly men,have no job at all. Almost universally, male discussiongroups speak of frustration, anger, and humiliation,stemming from the misery of joblessness and theinability to provide for their families. This anxiety isparticularly visible in reports from Eastern Europe andCentral Asia. In Kalofer, Bulgaria, a town with 4,200inhabitants, four men in their thirties had committedsuicide in the four months before the interviews.

• Social determinants of health• The social determinants of health are the conditions in which people are born,

grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.

• Responding to increasing concern about these persisting and widening inequities, WHO established the Commission on Social Determinants of Health (CSDH) in 2005 to provide advice on how to reduce them. The Commission's final report was launched in August 2008, and contained three overarching recommendations:

• 1. Improve daily living conditions 2. Tackle the inequitable distribution of power, money, and resources 3. Measure and understand the problem and assess the impact of action