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- William W Parmley, MD, MACC*
- ↵*Send correspondence to: William W. Parmley, MD, MACC, Editor-in-Chief, Journal of the American College of Cardiology, 415 Judah St, San Francisco, California 94122
While walking through the downtown section of San Francisco during the past Christmas season, I was struck by the stark contrast between the affluent, healthy shoppers and the poor, unhealthy homeless—including many women and some children. A few coins in the proffered cup seemed like a pitiful attempt to help these unfortunate poor. Recently, I (and other journal editors) received an uninvited Editorial from the International Poverty and Health Network (IPHN). The IPHN was formed in December 1997 following a series of conferences organized by the World Health Organization. We were asked to consider publishing at least some portion of the editorial. The statistics are so striking that I have elected to do so. It’s a sobering reminder of inequities in the world and the possibility of correcting them. The two principal authors are Iona Heath, General Practitioner, Chairman of the Intercollegiate Forum on Poverty and Health, London, U.K., and Prof. Andy Haines, Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London, U.K. (Reproduced with permission, BMJ 2000;320:1–2, © BMJ 1999.)
“Around 1.3 billion people live in absolute, grinding poverty on less than $1 per day despite the overall substantial growth of the world economy which doubled over the 25 years prior to 1998 to reach $24 trillion (1). Of the 4.4 billion people in developing countries, nearly 60% lack access to sanitation, a third have no access to clean water, and about 20% lack access to health care of any kind; a similar proportion do not have sufficient dietary energy and protein.
Economic disparities both within and between countries have grown, and in about 100 countries incomes are lower in real terms than they were a decade or more ago (2). By 1995 the richest 20% of the world’s population had 82 times the income of the poorest 20%. The world’s 225 richest people have a combined wealth equivalent to the annual income of the poorest 2.5 billion people in the world (47% of the world’s population) (1). At the same time, the world is facing a growing scarcity of essential renewable resources from deforestation, soil erosion, water depletion, declining fish stocks, lost biodiversity, and challenges such as climate change which are likely to impact particularly on poor, vulnerable populations.
Despite the overall dramatic increases in life expectancy which have occurred over the last century, health professionals should be concerned about growing inequalities in health and wealth (3). The precipitous decline in life expectancy in Eastern Europe, particularly in Russia, is a graphic example of how health may deteriorate as societies face sudden social and economic change accompanied by growing poverty. The gap in life expectancy between selected Western European countries and Russia was widened from about three years for men in 1970 to around 15 years in 1995; the figures for women show a widening from 4 to 10 years over the same period (4). This health crisis is centered particularly on adult mortality from chronic diseases and external causes, principally violence. The East Asian recession has been deep and severe, resulting in substantial falls in average per capita income in five countries, most notably in Indonesia, with likely effects on poverty and ill health.
Many African countries have total external debts that are more than 100% of their Gross National Product. Although there has been progress in canceling debt, only 22 of the 52 countries needing substantial or total debt reduction will actually see their annual payments reduced following the agreements made at the Cologne summit (5). Therefore, much still remains to be done, including monitoring how the World Bank and IMF propose to implement the debt reduction program and ensuring that the economic policy reforms they recommend are focused on reducing poverty.
Even among generally prosperous, industrialized nations, in countries including Spain, Finland, Sweden, Denmark, and the USA, there are many examples of growing socioeconomic inequalities in health over the last 20 years or so (4). In the UK, there has been a widening of the differential in all cause mortality between Social Class V (unskilled) and Social Class I (professional) from a 2-fold difference in 1970–1972 to almost a 3-fold difference in 1991–1993 (6).
It is a matter of particular concern that the lives of so many children are blighted by poverty and robbed of their physical and mental potential (7). Even in the USA, more than 1 in 4 children under the age of 12 have difficulties in obtaining all the food they need.
In the 20th century, development has all-to-often been equated with economic growth, but the link between economic prosperity and health, a key component of human development, is not automatic. A recent World Bank study of the causes of declines in mortality between 1960 and 1990 suggested that gains in income contributed around 20% to male and female adult mortality and under 5 mortality rate reductions (8). The researchers indicated that educational level amongst women and the generation and utilization of new knowledge were more important factors.
Poverty is a social construction with many dimensions including lack of basic education, inadequate housing, social exclusion, lack of employment, environmental degradation, and low income. Each of these diminishes opportunity, limits choices and undermines hope, and each poses a threat to health. Economic indicators focus primarily on income poverty, whereas health indicators provide a measure of the multidimensional nature of poverty. For this reason, health should be the preeminent measure of the success or otherwise of development policies in the next century. It is health, rather than economic indicators, which will demonstrate the importance of implementing policies across a range of sectors to slow the rate of depletion of renewable resources and, through the securing of human rights (9), will capitalize on the potential of those who are currently unable to improve their quality of life.
Over the next few years IPHN supporters will strive to reduce the burden of ill health due to poverty in the following ways:
Engaging in strategic discussions with international institutions such as the IMF, the World Bank, WHO and national governments to ensure that health is placed at the center of development and that health impact assessments of all policies are undertaken.
Promoting intersectoral action for health at the local, regional, and national levels by working with sectors such as education, business, agriculture and transport to develop and implement effective policies.
Building the evidence base on effective interventions to reduce inequalities in health and demonstrate how improved health can reduce poverty.
Facilitating exchange of knowledge between health professionals in North and South about effective ways of working.
Ensuring that education programs for health professionals include appropriate information on the impact of socioeconomic inequalities on health and what health professionals can do to reduce such inequalities.
Encouraging health professionals to work with local communities to improve the health of the poorest.
Monitoring trends in health inequalities and using the data to influence policy.
We invite others to join us in this endeavor.”
- American College of Cardiology
- ↵United Nations Development Programme, Human Development Report 1998, Oxford University Press, New York, Oxford 1998.
- ↵United Nations Development Programme, Human Development Report 1996, 1997, Oxford University Press, New York, Oxford 1996, 1997.
- ↵Whitehead M, Diderichsen F. International evidence on social inequalities in health, in Health Inequalities, ed. Drever F, Whitehead M, Office of National Statistics, London, The Stationary Office 1996.
- ↵Jubilee 2000 Coalition, Unfinished business. The world’s leaders and the millenium debt challenge. Jubilee 2000 Coalition, 1999, 1 Rivington St., London, EC2 A3DT
- ↵Drever F, Bunting J. Patterns and trends in male mortality, in Health Inequalities, ed. Drever F, Whitehead M, Office of National Statistics, London, The Stationary Office 1996.
- ↵UNICEF, The State of the World’s Children 1998, Oxford University Press, New York, Oxford 1998.
- ↵Wang J, Jamison D, Bos E, Preker A, Peabody J. Measuring country performance on health: selected indicators for 115 countries. Health, Nutrition and Population Series, Washington DC, The World Bank, 1999.
- Bagnoud F.-X.,
- Mann J.M.