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2007 - Social Evils, Poverty & Health
2007 - Social Evils, Poverty & Health
There is a close association between social circumstances and health. In India, there is a significant
burden of both communicable and non communicable diseases. Risk factors responsible for these
conditions are underweight, unsafe sex, unsafe water, poor sanitation and hygiene, indoor smoke
pollution, zinc, iron and vitamin A deficiency, tobacco use, high blood pressure, and high cholesterol.
All these risk factors are influenced by social factors and in India the more important factors are
poverty and illiteracy. Changing lifestyles as a result of rising incomes are significant risk factors
for non communicable diseases. The social evils that influence poverty and health are macrolevel
national and regional issues such as physical geography, governance patterns and failures, geopolitics,
economic policy, natural resources decline, population growth, the demographic trap and the fiscal
trap. Household and microlevel factors include the poverty trap, cultural barriers, lack of innovation
and saving, absence of trade or business, unemployment, technological reversal, adverse productivity
shock, social issues related to females, and adolescent social issues. Social determinants important
for non communicable diseases, defined by the World Health Organization include the social gradient,
stress, early life events, social exclusion, improper work conditions, unemployment, lack of social
support, addiction, food scarcity or excess and uneven distribution, lack of proper transport, and
illiteracy or low educational status. There are multiple pathways through which social factors
influence health, and pathophysiological mechanisms involve homeostatic and allostatic changes in
response to stress, neuroendocrine changes and altered autonomic functions, and abnormal
inflammatory and immune responses. A concerted action to eradicate these social evils shall have to
focus on reducing poverty, improving educational status and providing equitable and accessible
healthcare to all.
Key words Cultural barriers - health inequity - health risk - national issues - poverty - social evils
Poverty is one of the most important social evils causing community disturbances and poverty and vice
and a major determinant of ill health 1. From time versa was noted2. Health status is strongly determined
immemorial it is known that poor social status is a major by socio-economic position and a large body of literature
determinant of disease and reduces longevity. The from developed countries demonstrates that most causes
Charaka Samhita recognized that community structure of deaths occur at greater rate in groups with lower
and functioning was an important cause of disease in socio-economic status3. In this article we enumerate
an individual. The association of individual illness social circumstances and evils leading to poverty that
279
280 INDIAN J MED RES, OCTOBER 2007
Table I. Estimates of ten leading causes of deaths in Global Burden of Diseases Study
Developed countries Developing countries
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is a major social evil. Mechanistic pathways from Table II. Disease burden estimates in India (National Commission
adverse social circumstances to ill health are then on Macroeconomics and Health, 2005)
discussed and some suggestions are made for Disease condition Estimate of cases
ameliorating the social evils. (thousands)
Health issues in India and developing countries Diarrhoeal diseases per year 76000
Mental health 65000
The Global Burden of Diseases Study reported COPD and asthma 40500
major causes of mortality, disease burden and risk Diabetes 31000
factors thereof in various parts of the world4. The top Cardiovascular diseases 29000
Blindness 14100
ten leading causes of mortality in developed and Tuberculosis 8500
developing countries are shown in Table I. HIV/AIDS 5100
Cardiovascular diseases (ischaemic heart disease and Malaria and vector borne diseases 2037
cerebrovascular disease) are leading causes in all Injuries 980
regions of the world. In developing countries, Cancer 807
infections of respiratory tract, HIV/AIDS, diarrhoea, Source: Ref. 9
tuberculosis and malaria have emerged as important
causes. In India, leading major cause-groups of deaths
Ten leading causes of disability as assessed by
during 1984 to 1998 have been reported by the
disability adjusted life years (DALYs) has also been
Registrar- General of India5. Trends show that there
reported by the WHO8. Globally the important causes
has been a significant decline of proportionate
were lower respiratory infections, perinatal conditions,
mortality from infectious diseases from 22 to 16 per
HIV/AIDS, unipolar depression, diarrhoeas, ischaemic
cent whereas mortality from cardiovascular diseases
heart disease, cerebrovascular disease, road traffic
has increased from 21 to 25 per cent and due to injuries
accidents, malaria and tuberculosis. Indian National
from 8 to 12 per cent (P<0.05)5. The reliability of
Commission on Macroeconomics and Health 9 has
mortality data has been questioned in terms of medical
reported that communicable diseases, maternal and
classification of deaths as a large number of deaths
perinatal conditions as well as non communicable
are recorded as senility or old age and a major cause
diseases are major causes of disease burden (Table II).
of this group is cardiovascular disease, hence the
current sources may underestimate the deaths due to The Second Global Burden of Diseases Study4
cardiovascular diseases. The ongoing prospective quantified more than 20 health risk factors that influence
Sample Registration System Verbal Autopsy (SRS-VA) health of populations. Major risk factors identified were
Million Deaths Study in India6 and the Prospective (i) childhood and maternal undernutrition leading to
Urban Rural Epidemiology (PURE) Study7 would be childhood and maternal underweight, iron deficiency
able to provide more definitive answers regarding anaemia, vitamin A deficiency and zinc deficiency; (ii)
causes of deaths and their risk factors in India. adult nutritional factors related to high blood pressure,
GUPTA & KUMAR: SOCIAL EVILS, POVERTY & HEALTH 281
high cholesterol, and obesity; low fruit and vegetable collectively11. There are a number of social problems
intake, and physical inactivity; (iii) addictive substances in India 11. These have been identified as poverty,
use such as smoking and oral tobacco use, alcohol use, illiteracy, unemployment, population explosion,
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and illicit drug use; (iv) issues in sexual and reproductive communalism, secularism, and regionalization, youth
health and unsafe sex and ineffective contraception; (v) unrest and agitation, child abuse and child labour,
environmental and occupational risk factors such as violence against women, urbanization, crime and
unsafe water, sanitation and hygiene, urban air pollution, criminals, juvenile delinquency, alcoholism, drug abuse
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indoor air pollution from household use of solid fuels, and drug dependence, HIV-AIDS, terrorism, corruption,
lead exposure, global climate change and selected bonded labour, black money and more recently
occupational risk factors; and (vi) other selected risk overweight/obesity in the urban subjects coupled with
factors such as contaminated injections in healthcare changing lifestyles.
settings and child sexual abuse. There was a difference
in risk factors causing disease burden or mortality. The Multiple efforts to accurately identify social
top ten risk factors for mortality as well as increased determinants of health have been performed and some
burden of disease are shown in Table III10. Social efforts have evolved recently. Social determinants of
circumstances and poverty are the major determinants health were enumerated by Marmot and others at the
of all these factors. Solid Facts Program of the World Health Organization
(WHO)12. The factors identified were social organization,
Social evils early life events, life-course social gradient, high-
A social problem is defined as a situation unemployment rates, psychosocial work environment,
confronting a group or a section of society which inflicts transport, social support and cohesion, food, poverty and
injurious consequences that can be handled only social exclusion, and individual health behaviours. All
Table III. Top ten risk factors for increased mortality and burden of disease
Causes of increased burden of disease
Causes in different economic regions
Rank Major causes of Global causes High mortality Low mortality Developed regions
mortality developing regions, developing regions
such as India
1 High blood pressure Childhood and maternal Underweight Alcohol Tobacco
Underweight
2 Smoking and oral Unsafe sex Unsafe sex High blood pressure High blood pressure
tobacco use
3 High cholesterol High blood pressure Unsafe water, Tobacco Alcohol
sanitation and hygiene
4 Childhood and maternal Smoking and tobacco Indoor smoke from Underweight High cholesterol
underweight use solid fuels
5 Unsafe sex Alcohol use Zinc deficiency High BMI High BMI
6 Low fruit and vegetable Unsafe water, sanitation Iron deficiency High cholesterol Low fruit and vegetable
consumption and hygiene intake
7 Overweight and obesity High cholesterol Vitamin A deficiency Low fruit and Physical inactivity
vegetable intake
8 Physical inactivity Indoor air pollution High blood pressure Indoor smoke from Illicit drugs
solid fuels
9 Alcohol use Iron deficiency anaemia Tobacco Iron deficiency Unsafe sex
10 Unsafe water, sanitation Overweight and obesity High cholesterol Unsafe water, Iron deficiency
and hygiene sanitation and
hygiene
BMI, body mass index
Source: Ref. 4
282 INDIAN J MED RES, OCTOBER 2007
these factors are classified as social evils that directly individual. The noted economist, Jeffrey Sachs, has
influence health. Because non-communicable diseases provided listing of social determinants of poverty13.
are major health issues in Europe and developed countries These determinants can also be considered evils that
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these factors, though important in the Indian context, lead to poverty and their importance as determinants in
reveal only half the story. For example, illiteracy and health related outcomes can be evaluated (Table IV).
low educational status is a major disease risk factor but Multiple international and national level factors are
not part of the WHO agenda as this is not a serious important determinants of poverty and ill health.
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problem in Europe3. A major development to address Extreme poverty which has been defined by the World
various social issues and poverty was the landmark Bank as income of less than $1 per day per person ($1.08
United Nations Millennium Declaration in the year 2000 at 1993 prices and $1.53 at current prices) is a problem
by various Heads of States and governments. The of developing countries such as India. In year 2004,
declaration articulated Millennium Development Goals 986 million persons (18% of total world population)
(MDGs) 13 which include specific targets for social lived at this level. This is a sharp decline from 1.25
engineering to bring about equitable prosperity and billion (29% of the world population) in 1990 14 .
health. The specific targets include poverty reduction, Developmental economists speculate multiple reasons
increasing primary education, promoting gender equality, for this decline including changes in international,
reducing childhood mortality, improving maternal health, national, local governmental and municipal policies13.
combating infections such as tuberculosis, HIV/AIDS A better understanding of reasons of poverty and
and malaria, ensuring environmental sustainability, and amelioration of some of them has also led to this
development of a global partnership for development. situation. There are international and national factors
There are specific targets in areas of poverty reduction, amenable to significant improvement and include the
provision of education to all children, reducing the following:
percentage of people without access to water and
Physical geography: Nations are a geographic entity
sanitation, reduction in infant, childhood and maternal
and location-based geographical advantages and
mortality, control in spread of diseases such as HIV/AIDS
disadvantages play an important role in societal and
and malaria and improving the lives of slum dwellers.
economic development. Geographic location is also an
Social evils: National and regional issues important determinant of health. For more than two
thousand years it has been known that bad air causes
The social evils can be viewed at a macrolevel that
multiple diseases including infections and
include national and regional issues. They can also be
deficiencies15. Although scientifically erroneous (this
assessed at a microlevel of the household and an
hypothesis was explanation of malaria and cholera
Table IV. Major social determinants of poverty and ill-health epidemics), there is merit in considering these infections
National/Regional level factors:
a result of bad location. Other infections that are known
(i) Physical geography to be due to geographic disadvantage are yellow fever,
(ii) Governance patterns and failures African trypanosomiasis and many vector borne
(iii) Geopolitics diseases10. Nutritional deficiency syndromes in Sub-
(iv) Economic policy
(v) Natural resources decline
Saharan Africa are also a result of adverse locational
(vi) Population growth circumstances13. Non communicable diseases such as
(vii) The demographic trap chronic respiratory disease and asthma in specific
(viii) The fiscal trap locations of the world and especially high rates of
Household and local level factors: asthma in developed countries can also be explained
(i) Poverty trap by geographical factors16. Higher physical activity levels
(ii) Cultural barriers and low rate of obesity in rural locations in developing
(iii) Lack of innovation and saving
(iv) Absence of trade or business countries explain the rural-urban differences in coronary
(v) Unemployment heart disease 17 . Physical geography should be
(vi) Technological reversal recognized as an important determinant of poverty and
(vii) Adverse productivity shock identification of unique strong points can be an
(viii) Gender issues
(ix) Adolescent health issues important harbinger of social and economic change
leading to reduced ill health. Other geographic factors
Source: Ref. 13
related to health include transport conditions of the
GUPTA & KUMAR: SOCIAL EVILS, POVERTY & HEALTH 283
country and proximity to seaports and roads, costs of Refugee movements, terrorism and cross border warfare
transportation, and population density in various all have bearing on health. Trade barriers also impede
locations and availability of health care locally. economic development and sustain poverty, illiteracy
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distribution of poverty can also be estimated. These (cardiovascular disease, diabetes) in India can be partly
parameters provide important data on prevalence of explained by this change.
social evils in a country at the household level. It is
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Intermediate At least one tap in premises or About 50 litres per capita/day Low Low
access close by
Optimal access Water supply within house with 100-200 litres per capita/day Very low Very low
more than one tap
Source: Ref. 45
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