Prisoners of poverty

Posted: 16 August 2000

Author: Greg Goldstein

The problem of health and the environment may not be solvable without tackling poverty, says Greg Goldstein.

The subject of poor people in crowded settlements is bedevilled by a profound lack of interest. Yet, unless a major investment is made to ensure that all human beings are able to obtain the necessities of a decent life 'health for all' may remain no more than a slogan.

Attention may be given to settlements when a new type of epidemic disease threatens; when water shortage looms; or when the level of violence crosses various thresholds. Every type of human misery from crime to drugs to epidemic disease finds fertile soil in low income or squatter settlements and 'peri-urban septic fringes'. But strangely, the poverty and vulnerability represented by the world's poor settlements are tolerated and even exploited. Such conditions are accepted almost as naturally ordained.

Atul Ayub Colony behind Bhopal pesticide plant, IndiaRod Johnson/ Panos Pictures

Today, we live on a planet which increasingly represents not 'one world', but 'two worlds'. The 'two worlds' result in part from the failure of growth in more than 100 countries. As the UNDP Human Development Report has indicated, these countries' per capita income is lower than it was 15 years ago, and, as a result, more than a quarter of humanity ­ 1.6 billion people ­ are worse off today than they were 15 years ago.

A connection between advanced technology and scientific capacity to the desperate and degrading living conditions of poor citizens is never made. As a Spanish colleague who marvels at the wonders of science has noted "Why then don¹t we live with more dignity? Is there a Black Hand upon us?"

Mounting inequality

In 70 developing countries, today's levels of income are less than those reached in the 1960s or 1970s. Today, per capita income is less than it was in 1960 or before. Economic decline in much of the developing world has lasted for longer and gone deeper than the Great Depression of the 1930s.

Poverty and income gaps have grown amidst economic growth. The World Bank recently estimated that 1.3 billion people live ­ or survive ­ on less than a dollar a day. The number of people with incomes of less that $750 per year, hardly more than $2 per day, is about 3.3 billion people, or 60 per cent of humanity. We live in a world where between 1960 and 1993 total global income increased by six-fold to $23 trillion, and where average world per capita income tripled, but where three-fifths of humanity still lives in a prison of poverty.

Poverty and health

In many countries during the last two decades, the ratio of the share of income of the richest 10 per cent to the poorest 10 per cent of the population more than doubled. In Thailand, for example, it grew from 17 times to 38 times. And today, in the United States, the share of total assets owned by the richest one per cent of the people has almost doubled from 20 per cent to 36 per cent since 1975. In countries like Brazil and Guatemala the richest 20 per cent earn more than 30 times the poorest, and even in the United States, the United Kingdom, Switzerland and Australia, the difference is about ten-fold.

During the last three decades, the ratio of the income share of the richest 20 per cent to that of the poorest 20 per cent has more than doubled from 30:1 to 61:1. The poorest 20 per cent saw their share of global income decline from 2.3 per cent to 1.4 per cent over the last 30 years.

The last few decades have seen evidence accumulating about relationships between poverty and poor health. In an important new analysis that draws on recent research from many disciplines, Richard Wilkinson has shown how the effects of poverty are mediated through low social cohesion, marginalization of poor people, and lack of social participation¹. The startling possibility has emerged that the serious health problems of poor people are not only the result of a lack of clean water, a decent house, sanitation and basic services. They also result from despair, anger, fear, worry about debts, worry about job and housing insecurity, feelings of failure and social alienation.

He shows for example that the decline in social cohesion in Eastern Europe in the 1970s and 1980s is clearly related to the widening East-West mortality gap. The conclusion is that chronic stress ­ arising from social exclusion and devaluation as a human being ­ may be as damaging to health as the dangerous housing and working conditions poor people experience.

Polarization, increased inequality and profound poverty not only violate basic principles of justice and fairness, they breed alienation, despair and crime. More egalitarian societies connect people through a variety of social organizations, purposes and activities. The necessary contribution of poor people to sustainable development may never be realized without major investment in their development. If ambitious agendas on conservation, energy, food, women and ecological city planning are ever to be achieved, the first step may be to develop the conditions whereby social cohesion and social purpose are possible.

New global agenda

The desperate problems of urban infrastructure and services have implications not only for poor countries or African countries. A new global agenda (funded by wealthier countries) to solve the settlements problems in all countries may be in the best interest of wealthier as well as poorer countries.

Gradually it is becoming clearer that 'globalization' does not only involve trade and communications, but also many types of important social and environmental issues, including infectious diseases, crime, drug problems and environmental damage. It has not passed unnoticed that diseases such as tuberculosis and cholera, once thought to be eradicated by most high or middle-income countries, are now a threat to many people worldwide, and that their comeback is related at least in part to poor housing conditions and deficient basic services in settlements. Laurie Garrett has argued that the emergence of new diseases such as Ebola virus infection has been facilitated through the presence of unplanned and poorly serviced settlements². Perhaps the question is not "can we afford to provide decent housing and basic services for all humans", rather it is can we ­ the human species ­ afford not to?

A major international effort is needed to develop our towns and cities in such a way that all citizens can live a decent life ­ using existing capabilities and technologies. In conference after conference in the last decade of the millennium, ambitious agendas have been developed on sustainable development. But still needed is a greater recognition of the corrosive effect on these agendas of continued and rising inequity on the sense of purpose and social cohesion at global, national and local levels. The global web of trade, grassroots and NGO action, investment, diplomacy, and telecommunications must continue to be strengthened to develop this purpose.

The world's rich minority (the 30 richest countries) represent 78 per cent of the global gross domestic product. Currently the global rich spend only an average of 0.25 per cent of their national income on official development aid. Is such a small figure in their best interest? Effective aid does not depend only on its amount, but also requires action by recipient countries in strengthening the legitimacy, transparency and the accountability of their institutions.

Dr Greg Goldstein is Co-ordinator of the Healthy City Programme at WHO in Geneva.

1. Unhealthy Societies. The Afflictions of Inequality. Richard Wilkinson, Routledge, New York, 1996.
The Return of Infectious Diseases, Laurie Garrett, Foreign Affairs, January, 1996.