Intended for healthcare professionals


Extreme poverty: an obligation ignored

BMJ 1996; 313 doi: (Published 13 July 1996) Cite this as: BMJ 1996;313:65
  1. John Kevany
  1. Associate professor of international health Department of Community Health and General Practice, Trinity College, Dublin 2, Republic of Ireland

    Breaking the cycle between poverty and ill health needs multisectoral action

    The world's biggest killer and the greatest cause of ill health and suffering across the globe is listed almost at the end of the International Classification of Diseases. It is given code Z59.5—extreme poverty.1

    Extreme poverty is defined as a level of income or expenditure below which people cannot afford a minimum, nutritionally adequate diet and essential non-food requirements.2 The effects of poverty on health are never more clearly expressed than in poor communities of the developing world. The absence of safe water, environmental sanitation, adequate diet, secure housing, basic education, income generating opportunities, and access to health care act in obvious and direct ways to produce ill health, particularly from infectious disease, malnutrition, and reproductive hazards.3

    Today the number of people in extreme poverty is estimated at 1.1 billion—a fifth of the world's population. The wealthiest fifth of the world's population now controls 85% of global gross national product and 85% of world trade, leaving the poorest quintile with 1.4% of gross national product and 0.9% of world trade.4 This extraordinary gap continues to widen, to an extent that human poverty has now become institutionalised on an unprecedented scale.

    In real terms, poverty is the principal cause of the 12.2 million deaths a year in children under 5; 4.1 million of these deaths arise from acute lower respiratory tract infections and a further 3 million from diarrhoea and dysentery.1 Malnutrition is estimated to be an underlying cause in 30% of child deaths and is overtly expressed as growth retardation in 230 million children and severe wasting in 50 million children.1 In adults, poverty accounts for much of the annual 2.7 million deaths from tuberculosis and 2 million deaths from malaria.1 Maternal mortality is strongly associated with high fertility and lack of access to health services and causes a further 500 000 deaths a year, with their associated impact on surviving offspring.1 The scale and persistence of these problems, despite global immunisation levels of around 80% and a gradual improvement in life expectancy in most countries,1 is a blunt reminder of an obligation ignored.

    At country level, the World Health Organisation has traditionally been obliged to operate strictly within the health sector and through the highly centralised administrations and rigid bureaucratic systems that characterise most poor countries. But poverty alleviation requires a multifaceted approach, generated by the community itself and integrating inputs from different sectors such as public works, housing, agriculture, and education. It also requires long term commitment to community development through social organisation, needs assessment, political engagement, skills training, and resource mobilisation. Such a process may require support for up to 20 years to become sustainable. To respond to these new operational requirements, WHO established the Division of Intensified Cooperation with Countries in 1989, to focus on health policy development, systems planning and management, and health care financing. Most importantly it undertakes to coordinate and manage external aid flows for health in some countries. On an annual budget of $18m it works closely with more than 30 of the world's poorest countries

    In developing its long term strategy to combat poverty, the new division recognised that non-governmental organisations, both national and international, had a long record of successful experience. It therefore organised a series of consultations with groups of non-governmental organisations to inform its planning process and strengthen its operational links with these agencies. The third of these meetings was cosponsored by the Irish government and took place last month in Maynooth, Ireland. It was attended by a range of nongovernmental organisations operating in sub-Saharan Africa: Concern Worldwide, Medecins Sans Frontieres, Medicus Mundi International, Oxfam, Save the Children, Trocaire, World Council of Churches, and several other international and national agencies.

    The meeting focused on the role of non-governmental organisations in stimulating community based health initiatives, on the need to think and act multisectorally, and the importance of long term commitment by donors. It closed on the need to engage world attention at the end of the millennium on the impact of poverty on ill health and to strengthen advocacy on this issue by intensive national and international lobbying, by generating health statistics disaggregated by income, and by presenting an image of poverty as an unacceptable waste of human resources. The final consultation in this series of meetings with non-governmental organisations will be cosponsored by WHO and the state of Maryland, USA, as part of the International Health Congress to take place in Baltimore in September 1997. This meeting will consider integrated strategies for breaking the cycle of poverty and ill health in the urban environment and will examine mechanisms for involving the business sector in creating economic opportunities. It is hoped that this partnership between WHO and the non-governmental organisations will restore a much needed moral and social dimension to an international health ethos grown progressively dependent on technological innovation and free market economics.


    1. 1.
    2. 2.
    3. 3.
    4. 4.
    View Abstract