Poverty and health: an age-old problem
May 30, 2017
Last week I moderated a panel entitled “Poverty and Public Health: Addressing the Causes and Consequences” held as part of the Public Health Grand Rounds series sponsored the Philadelphia Department of Public Health and the Section on Public Health and Preventive Medicine of the Philadelphia College of Physicians and Surgeons. The panel took place in a beautiful wood paneled hall of the distinguished College. Four speakers gave very different perspectives on the topic ranging from a discussion of the possible impact of social and economic policies on poverty (and its health consequences) to reflections on the personal experience of poverty and the very immediate and tangible ways in which it affects all of life, including health of course. The Drexel Urban Health Collaborative (UHC) released a data brief illustrating the links between neighborhood poverty and heath using recent data from our city, Philadelphia.
The strong and pervasive relationship between poverty and health is of course not new, it has been described and documented an infinite number of times in many, many different ways. Poverty can be thought of as a fundamental cause of ill health, acting through many different mechanisms on many different health related processes. We know that blocking one of the pathways is not sufficient: new pathways emerge. In places and times when infectious diseases are common, the poor suffer and die more frequently from infectious diseases, but when infectious agents are controlled, the poor die of chronic diseases, like heart disease and cancer. Injury, violence, and mental illness are also linked to poverty.
Poverty affects health in such a profound way because being poor is a marker for cumulative exposure to many things that reinforce and potentiate each other. Poverty is a cause of stress which influences and interacts with health-related behaviors like smoking, dietary habits and physical activity. The physical environment of poor neighborhoods, including access to healthy or unhealthy foods and advertising, facilitate and reinforce the use of behaviors like smoking or consumption of calorie-rich or high fat foods as ways to cope with poverty-linked stress. Toxic exposures like air pollution have direct effects on health conditions like asthma or cardiovascular disease and may themselves interact with stress, unhealthy diets, or sedentary life styles.
Work conditions among the poor – including lack of employment or unstable employment, or jobs linked to unhealthy exposures or that lack in control or social support – may also have adverse health consequences. Violence and lack of safety also contribute to poor health. For historical, social, and economic reasons, poverty is more highly concentrated in African Americans and Latinos, resulting in compounded effects of poverty and racism on health.
Poverty is also strongly spatially segregated such that poor families tend to live in neighborhoods where others are poor, and poor neighborhoods are often surrounded by other poor neighborhoods. This spatial concentration of poverty results in marked difference in the social and physical environments of poor and non-poor neighborhoods. A multiplicity of factors create these differences including marked differentials in political power and economic resources as well as subtle effects of discrimination. These factors result in profound differences in access to services and in the physical quality and social environment of neighborhoods. These factors also affect health and reinforce residential segregation, creating a vicious cycle that magnifies differences across neighborhoods in poverty, in environmental quality, and in health.
So what can be done? Should we throw up our hands and give up? The speakers on the panel provided insights. Giridhar Mallya, MD, MSHP, Senior Policy Officer, Robert Wood Johnson Foundation, spoke of the use of policy levers like the earned income tax credit or neighborhood improvement policies. Mitch Little, MS, Director, Philadelphia Mayor's Office of Community Empowerment and Opportunity, discussed the role of place–based initiatives including housing, improved early education, access to career pathways, and promotion of food security. Natalie Levkovich, Executive Director, Health Federation of Philadelphia, talked about the critical role of community heath centers and the many ways in which they can care for the underserved. Imani Sullivan, Witnesses to Hunger, reminded us of the importance of looking beyond the statistics and bearing witness to the tangible and immediate ways in which poverty affects real people every day.
Perhaps the most important message that emerged from this panel was that addressing the impact of poverty on health will require many sectors working together (social policy, economic policy, neighborhood initiatives, education, and health care, among others). Health care is of course important but not sufficient. All lifestages are affected but reducing the impact of poverty in children is especially important as it will yield many benefits, including health benefits much later in life.
Nearly thirty years ago as a pediatric resident I worked in a health center in a large villa called “Ciudad Oculta” (“hidden city”), a very poor neighborhood in Buenos Aires. It was called “Hidden City” because when you drove by you would never imagine the thousands of people who lived there, with no proper streets, no formal access to water or electricity, in informal houses built by the residents of brick, cement, and tin. As part of my job I did home visits vaccinating against measles. Every day I cared for children with infections and growth delays, all of which could be linked to the poverty conditions in which they lived. The same children came back day after day and I knew that what I did as a doctor had limited impact. I examined them, I questioned their parents, I prescribed, and I scheduled follow-ups. I remember a few of these children vividly. When they visited they would run towards me down the long cavernous hall in the unfinished mammoth cement construction that housed the health center in the ground floor, the only finished section of the whole building. I recently heard that the vacant floors that towered above the health center have since been torn down, but the villa, Ciudad Oculta, is there still.
Sometimes I wonder what has become of the children I saw, where they are now, what their lives turned out to be like. It is very possible that health is the least of their worries….. Eliminating poverty is fundamentally a moral issue and a justice issue, not a health issue. But poverty also happens to be a fundamental cause of ill-health. Addressing these fundamental causes in ways that are inter-sectoral, informed by science, and responsive to the needs and experiences of communities and real people, as discussed by the panel, remains a critical part – perhaps one of the most important parts – of our public health mission.