Читать книгу Health Psychology - Michael Murray - Страница 61

Of 7.2 billion people alive in 2014, approximately 5 billion (70%) live in so-called ‘developing’ countries, i.e., low- and middle-income countries, the word ‘developing’ being a polite euphemism for ‘poor’. Poverty, by whatever name, exists on a massive scale: 1 billion to 1.5 billion people live on less than US$1.25 per day – i.e., more than one person in every five. For them, clean drinking water, flushing toilets, health services and modern medicines are completely out of reach. Initiatives that have attempted to improve the health of people in extreme poverty mostly have failed.

The UN Development Programme defined poverty as ‘a level of income below that people cannot afford a minimum, nutritionally adequate diet and essential non-food requirements’ (United Nations Development Programme, 1995). Half of the world’s population lacks regular access to medical care and most essential drugs. International organizations such as the UN state with some justification that poverty is the greatest cause of ill health and early mortality. The health effects of poverty are tangible and the biological and economic mechanisms are the same everywhere. The major impacts of poverty on health are caused by the absence of:

 safe water;

 environmental sanitation;

 adequate diet;

 secure housing;

 basic education;

 income-generating opportunities;

 access to medication and health care.

These are familiar themes. The most common health outcomes of poverty are infectious diseases, malnutrition and reproductive hazards (Anand and Sen, 2000). Poverty implies a lack of access to necessary medicines. HIV infection and AIDS provide a good example. A major killer disease is AIDS (acquired immune deficiency syndrome). In 2004, 6 million people living with HIV infection and AIDS in developing countries urgently needed access to highly active antiretroviral therapy (HAART). The World Health Organization (WHO) began the ‘3 by 5 Initiative’ in 2004 when less than 10% of sufferers had access to HAART. The WHO set a target of providing HAART to 3 million people living with HIV infection or AIDS by the end of 2005. The data show that this figure was half met. However, the number of people accessing antiretroviral therapy in low- and middle-income countries has risen, and reached an estimated 6.6 million at the end of 2010. The major barrier to increasing access to HAART is cost. The pharmaceutical industry holds the patents and loses profits if patent rights are relinquished to enable the generic production of HAART medication. Further discussion of HAART can be found in Chapters 8 and 22.

Economic growth refers to the rate of increase in the total production of goods and services within an economy. Such growth increases the capacity of an economy to produce new goods and services, allowing more needs and wants to be satisfied. A growing economy increases employment, and stimulates business enterprise and innovation. Sustained growth is fundamental to the raising of living standards and to providing greater quality of life (QoL). A key concept is gross national income (GNI), which is the monetary value of all goods and services produced in a country over a year. GNI is therefore a useful indicator for measuring growth.

BOX 4.1 INTERNATIONAL EXAMPLE: Reducing poverty in Brazil

The Brazilian economy came under the media spotlight in June 2014 when it hosted the FIFA World Cup. In spite of its anti-hunger programme, protests and strikes in Brazil’s cities were a prominent feature of the 2014 World Cup. Life in the favelas was shown in TV documentaries as exotic, entrepreneurial and exciting, in spite of the child prostitution, drug trafficking and extremely impoverished communities. Graffiti art was used to draw attention to the contradiction between the lavish expenditure on 12 new stadia and the chronic levels of extreme poverty among a large proportion of the Brazilian population.

At the United Nations in 2000, 189 countries adopted the ‘Millennium Development Goals’, including halving poverty rates by 2015, reducing child mortality, decelerating the growth of AIDS and educating all children. In the early 2000s Brazil was working towards, and expected to reach, these targets using the Bolsa Família (family stipend) and Fome Zero (zero hunger) programmes (Galindo, 2004). Doctors at a local health clinic in Brazil observed that their patients, who regularly came in with health problems related to poverty, were visiting less often. This can be reasonably attributed to the national, anti-hunger Fome Zero (zero hunger) programme that aimed to give every Brazilian at least three meals a day. With one-quarter of Brazil’s 170 million people below the poverty line, this goal was a challenge. To date, the government has provided emergency help to 13 million families.

The scheme involved giving ‘something for something’ by making cash transfers conditional upon regular school attendance, health checks, and participation in vaccination and nutrition programmes. Almost three-quarters of benefits reached the poorest 20% of the population and absolute poverty halved from 21% in 2001 to 11% in 2008 (Hall, 2012). Opinions vary about the success of the programme. Commentators suggested that the Workers’ Party gained many extra votes as one consequence of Bolsa Família, and also that there was shift in policy towards short-term solutions to poverty rather than long-term investments in health and education (Hall, 2008, 2012).

The production of good population health requires much more than simply providing doctors, nurses and hospital services. Basic economic, educational and environmental foundations need to be put into place. This means that some fairly dramatic economic changes are needed if we are to see health improvements during the twenty-first century. Among these changes, the cancellation of unpaid debts of the poorest countries and trade justice have the potential to bring health improvements to match those of the last 50 years.

A case can be made that health improvements are a necessary precondition of economic growth. This was suggested by the WHO Commission on Macroeconomics and Health. The Commission Report stated: ‘in countries where people have poor health and the level of education is low it is more difficult to achieve sustainable economic growth’ (World Health Organization, 2002). If current trends continue, health in sub-Saharan Africa will worsen over the next decades. If the Millennium Development Goals are going to have any chance of success in Africa, health must be given a higher priority in development policies. Sub-Saharan Africa contains 34 of the 41 most indebted countries, and the proportion of people living in absolute poverty (on under US$1 per day) is growing. The health of sub-Saharan Africans is among the worst in the world. Consider the following indicators:

 Two-thirds of Africans live in absolute poverty.

 More than half lack safe water.

 A total of 70% are without proper sanitation.

 Forty million children are not in primary school.

 Infant mortality is 55% higher than in other low-income countries.

 Average life expectancy is 51 years.

 The incidence of malaria and tuberculosis is increasing.

These figures indicate the very large gaps that exist between the ‘haves’ and ‘have-nots’ on the international stage. International debt is a significant factor in poverty. Rich nations will need to honour pledges they have given to cancel debts and establish fair trade to produce reductions in poverty and hunger in Africa.