Intended for healthcare professionals


Working together to reduce poverty's damage

BMJ 1997; 314 doi: (Published 22 February 1997) Cite this as: BMJ 1997;314:529

Doctors fought nuclear weapons, now they can fight poverty

  1. Andrew Haines, Professor of primary health carea,
  2. Richard Smith, Editorb
  1. a Joint Department of Primary Care and Population Sciences, Royal Free Hospital School of Medicine and University College London Medical School, London NW3 2 PF
  2. b BMJ, London WC1H 9JR

    Next week the Royal Colleges of General Practitioners, Nursing, and Physicians, the Faculty of Public Health Medicine, Action in International Medicine (an organisation of colleges and academies of health professionals with member institutions in 30 countries), and the BMJ will hold a conference on poverty and health. The conference will be part of worldwide professional activity to reduce the harmful effects of poverty. This week the BMJ publishes its fourth issue in two years that has clustered papers on inequalities in health. Why all the fuss?

    Some suggest that it's because the BMJ is politically motivated. If that means the BMJ wants action on a major threat to health, it's true. We would like all political parties in all countries to pay attention to inequalities in health. Many are reluctant to do so. They are more concerned to cut taxes and so win the votes of what the economist J K Galbraith calls the comfortable majority.1

    We are publishing these special issues of the journal for four main reasons. Firstly, anybody interested in health has to pay attention to wealth. It's the single most important driver of health worldwide, even more important than smoking. Secondly, a great deal of research is under way into inequalities in health. It affects every part of medicine. We are beginning to understand that, for developed countries, relative poverty (having an income substantially below the mean for that society) is a more important influence on health than absolute poverty (lacking the basic means to live). 2 3 And this research is leading to important discoveries on how social pressures lead to disease outcomes.2 The BMJ receives many papers on inequalities in health, and many of them make it through our peer review process. It seems sensible to cluster them.

    Thirdly, things are getting worse not better. The gap between the rich and poor is tending to widen both between and within countries-with inevitable effects on health. Our final reason for publishing these special issues that cluster papers on inequalities in health is that there is increasing evidence on what health workers and health services can do to diminish the harmful effects of inequalities in health.4 5 6 England's chief medical officer will address next week's conference, and he and the Department of Health are taking an increasing interest in inequalities in health.4 7

    The overall gains in health that have occurred around the world are being overshadowed by increasing disparities between rich and poor. The number of people in absolute poverty increased over the latter half of the 1980s and now comprises more than one fifth of humanity.8 Since 1980 economic decline or stagnation has affected 100 countries, resulting in reduced incomes for 1.6 billion people. 9 Between 1990 and 1993 average income fell by 20% or more in 21 countries, particularly in eastern Europe and the countries of the former Soviet Union. 9

    The net worth of the world's 358 richest individuals is equal to the combined income of the poorest 45% of the world's population-2.3 billion people. A comparison of wealth alone would, no doubt, be even more dramatic since the wealth of poor people is usually much less than their income.9 Between 1960 and 1991 the ratio of the shares of the global income of the richest 20% of the world's population to the poorest 20% increased from 30:1 to 61:1.9

    The polarisation of wealth has become grotesque, and we are seeing the consequences. For example, life expectancy among men has declined in some of the countries of eastern and central Europe over the past five years, and in Russia and the Ukraine infant mortality has risen. Dramatic increases in preventable diseases such as diphtheria, typhoid, and whooping cough have occurred.9 Worldwide, around a third of children under 5 show evidence of malnutrition as judged by their weight for age.8

    In Britain, income distribution has become more unequal, and, says the United Nations Development Programme, it is now one of the most unequal industrialised countries in the world. 9 For example, the proportion of people with an income below half the national average rose from under 10% in 1982 to over 20% in 1993.10 It has since fallen back to around 19%.10 Unskilled men now have a mortality three times that of professional men.11 This is a widening from a twofold differential in the early 1970s. In the 1980s this was equivalent to a five year difference in life expectancy for men aged 20.12 Now it will be wider.

    A study in the north of England showed that there has been a substantial rise in mortality in men aged 15-44 in poorer electoral wards as well as widening differences in mortality between rich and poor.13 The latest national figures in Britain showed a fall in life expectancy for young men for the first time this century.14 It's highly likely that poverty and social inequalities are contributing to this fall.

    A prospective study we publish today shows that socioeconomic factors act cumulatively over a lifetime: men born to fathers with manual jobs, who started their working life in manual jobs, and remained in them had an age adjusted relative death rate 70% higher than those who were born to fathers with non-manual jobs and then worked themselves in non-manual jobs.15

    Next week's London conference is part of a growing range of international activities to promote greater equity in health and health care. It was prompted by the “London declaration” produced at a conference organised by Action in International Medicine and the World Health Organisation (see box).16 The declaration has led to worldwide activity. For example, the American College of Physicians is hosting a symposium on international health at its 1997 annual meeting. A major conference is planned in Baltimore in September to discuss the challenges of improving health in deprived urban environments in North America. In the Philippines the Academy of Family Physicians has set up a task force on health and poverty and is discussing with the government how to expand the coverage of primary care.

    The London declaration16

    All institutions and associations of health professionals should:

    • Urge political leaders of their country to make public commitments to reduce poverty and improve the health of their populations

    • Exchange and disseminate information on trends in health and poverty and on successful and failed interventions directed at tackling their causes and effects

    • Recognise, harness, and enhance the potential energy resource of poor people themselves

    • Work to direct more health resources to the district level of their healthcare systems

    • Foster and coordinate intersectoral and interagency collaboration, especially at district level

    • Work to eliminate the marginalisation of population groups such as lonely elderly people, disabled people, and refugees

    • Ensure that front line health workers have appropriate training and the ability to access and use relevant information

    • Influence public opinion by liaising with national and international media

    • Lobby governments to reduce their economic dependence on harmful activities, such as the arms trade, narcotics, nicotine, and alcohol.

    The World Health Organisation, together with the Swedish International Development Agency, has called for greater equity in health and health care17 and is encouraging consultation on the renewal of its “Health for All” strategy, which includes a strong commitment to reduce poverty and its consequences for health.18 United Nations agencies have launched the 20:20 initiative, which proposes that 20% of aid budgets and of developing country budgets should be allocated to basic social services including health and education.19 This contrasts with the decline in overseas development assistance to the lowest level in real terms for 25 years. Of this only a tiny proportion goes to basic education and health care.20

    We now need greater coordination between bodies representing health professionals, international agencies, and non-governmental organisations concerned with health and development. Only by concerted efforts will there be any impact on the policies of national governments and bodies, such as the World Bank, that are major sources of funding for health. Health professionals can play an important part in this process by showing their indignation at the continued wastage of humanity and acting as advocates for effective policies to reduce poverty and its consequences for health. Although much effective action may lie outside the health sector, there is good evidence that cost effective basic services can improve health in conditions of extreme poverty,5 and a recent systematic review of effective interventions for “developed” countries has been conducted by the NHS Centre for Reviews and Dissemination.6 There is a need for sustained action because, with growing populations and major environmental threats to the health of vulnerable populations such as climate change,21 the toll exacted by poverty on human health is likely to grow in absolute terms without substantial shifts in policy and practice.

    Doctors won the Nobel peace prize for their international campaign against nuclear weapons. Now the same worldwide, professional energy should be concentrated on combatting the damage done by poverty.


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