Page 6 - Moravian Messenger June 2019

Poverty and Health
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The word 'poverty' has become a controversial one, for while the Oxford dictionary definition is simple enough - 'The state of being inferior in quality or insufficient in amount' - the outworking of the concept and what constitutes actual poverty is extremely sensitive and often goes to the core of political belief and ethos. This holds true at a local, national and international level. Clearly the consequence of poverty may affect people's lives in many ways, particularly in relation to lifestyle, education and health.
There have been many attempts at defining the concept of health but Dietrich Bonhoeffer simply yet comprehensively claimed it was 'the strength to be'1. In other words, health can be seen as 'the ability to flourish without being unduly impeded by illness or disability or, if necessary, by overcoming illness or disability.'2
The topic of 'Poverty and Health' has filled numerous volumes going back to the early nineteenth century and in trying to present a succinct contemporary overview reference will be made to two recent books which are well worth reading to gain a deeper appreciation of this complex topic.
'Factfulness'3, the international best seller by the renowned physician and statistician, Hans Rosling aims to give a more fact-based view of the world and challenges old prejudices in favour of a global and historical view. Rosling demonstrates that audiences all over the world consistently overestimate poverty in the world (the majority of the world live in middle income countries) and underestimate both life expectancy (the global average is 72 years) and the number of children vaccinated (80% of all children) and generally think the world is worse than the data indicates. Interestingly he also describes reasons why we have a tendency to pessimism including a possible evolutionary advantage. It may be a surprise to learn that 80% of the world's population now have access to electricity and the proportion of people living in extreme poverty has halved in the last 20 years. However while it is true that people are living longer, more educated lives than they used to, world hunger is also on the rise and people in rich countries are arguably less healthy than ever. Overall there is progress but there also remains much still to do. Clearly perspective and an appreciation of the facts are central to an understanding of the issues involved.
In the UK the National Statistics relating to 'Household Below Average Income' have just been published (March 2019). They state 'Looking at trends over the past 50 years, incomes across the population have increased dramatically in real terms over time, driving falls in absolute low income. This pattern has held fairly consistently over time, with rises in absolute low income relatively rare. Over the 1980s, however, incomes for those further up the income distribution grew more quickly than for those at the bottom, driving large increases in income inequality
and in relative low income measures.'4 In relation to health and poverty in the UK the key phrase here is 'income Inequality' and the fact that this is rising.
The opening line of Professor Sir Michael Marmot's most recent book, 'The Health Gap'5 states 'Why treat people and send them back to the conditions that made them sick?' The message of the book is that when thinking about health or health outcomes the tendency is to consider the availability and quality of health care whereas the reality is that the factors influencing our health, on a global, national or local scale, often have less to do with health care than with societal factors such as poverty and how empowered people feel.
The 'inverse care law' was suggested over forty years ago, by GP researcher Dr Julian Tudor Hart, to describe a perverse relationship between the need for health care and its actual utilisation. It describes how those who most need medical care are least likely to receive it. Conversely, those with least need of health care tend to use health services more (and more effectively).6 What this means in practice is that important health messages, (eat properly or exercise regularly) and lifestyle choices, (stop smoking, moderate alcohol intake) will not be followed if people do not feel empowered in their life. Clearly advice about eating well is unlikely to be meaningful to someone who is struggling to pay their bills or worried about some other perceived more pressing concern. The clear implication is that changing societal conditions will improve health. Dramatic differences in health are not a simple matter of rich and poor; poverty alone does not drive ill health, but inequality does. Indeed, suicide, heart disease, lung disease, obesity, and diabetes, for example, are all linked to social disadvantage. In every country, people at relative social disadvantage suffer health disadvantage and shorter lives. Marmot suggests that while the usual approaches to improving health have emphasized access to technical solutions and changes in the behaviour of individuals, these methods are limited. What really makes a difference is creating the conditions for people to have control over their lives and to have the power to live as they wish. Empowerment is the key to reducing health inequality and thereby improving the health of everyone.
However we choose to define poverty it is hard to disagree with Marmot when he states 'a good society is one in which the health of the population is good, health equity is high, and both improve over time.'5 If we achieve that then everyone can hope to have 'the strength to be' and the ability to flourish.
Dr David Johnston
Gracehill Congregation
1 Bonhoeffer D. Letters and papers from prison. London: SCM Press, 1953
2 Misselbrook D. Br J Gen Pract 2014; 64 (628): 582.
3 Rosling H. et al. Factfulness: Ten Reasons We're Wrong About the World - and Why Things Are Better Than You Think. New York: Flatiron Books, 2018 4 https://www.gov.uk/government/statistics/households-below-average-income-199495-to-201718
5 Marmot M. The Health Gap. London: Bloomsbury, 2015
6 https://www.kingsfund.org.uk/publications/articles/inverse-care-law