Book Extract: Why poor health hounds the poor

Title: Pulse to Planet: The Long Lifeline of Human Health

Author: K. Srinath Reddy

Publisher: HarperCollins India

Price: Rs 599

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Education or health? COVID-19 planted a cruel question for educators and public health experts to brood over. For two years, schools and colleges in most parts of the world were closed.

The reasons offered were that viral transmission was to be curtailed and young persons were both vulnerable to infection and could become active agents in infecting vulnerable adults because of their high mobility.

This had to be considered against the loss of education, which is well recognised to be an important agent for promoting health among individuals and populations.

What would be the delayed health effects of interrupted education? Besides, of course, the immediate COVID-19 related effects on mental health, through isolation and lack of socialisation with peers in a period of heightened anxiety, fear and grief? Or the rise in child obesity levels stoked by anxiety-driven overeating of junk foods and enforced physical inactivity?

Education: a positive influence on health

It is an axiom of public health that education improves the health of societies and protects the health of individuals. ‘A good quality education is the foundation of health and well-being.

For people to lead healthy and productive lives, they need knowledge to prevent sickness and disease.’ This is a declaration by the United Nations Educational, Scientific and Cultural Organization (UNESCO) that further affirms that ‘education is a catalyst for development and a health intervention in its own right’.

The Incheon Declaration of 2015 on Sustainable Development Goals affirms that education endows the skills, values and attitudes that enable citizens to lead healthy and fulfilled lives and make informed decisions. In a bidirectional relationship, ill health impedes access to education and the attainment of knowledge and skills.

There is a wealth of evidence, from comparisons within and across countries, that bears out these assertions on the positive impact of education on the health status of individuals and populations. Higher levels of education usually provide greater access to health-related information which, when assimilated and stored as knowledge, can promote and sustain healthy behaviours.

Education also increases opportunities for higher-income-earning employment. Better economic status, in turn, enables a person to afford more nutritious and safe food, live in better housing with the assurance of clean water and sanitation and amidst healthier physical and climatic surroundings.

Higher income, coupled with good education, also allows one to access better healthcare. Health-seeking behaviours, insurance literacy, ability to engage in participatory decision-making with the treating doctor, adherence to treatment and capacity for self-care are all better with higher levels of education. Worldwide, unhealthy behaviours such as tobacco consumption and alcohol abuse are negatively correlated with educational status. […]

Social media, formal and informal channels of education

The positive relationship of education with health was clearly evident in the twentieth century. However, the rapid growth of social media in the twenty-first century is blurring the benefit.

The best-case scenario is of widespread rise in health and nutrition literacy through print, electronic and social media. While it is happening to some extent, the infiltration of fake news and anti-science propaganda into social media has proved harmful in the adoption of healthy behaviours.

This has been painfully evident during the COVID-19 pandemic. Highly educated persons became prejudiced purveyors and deluded victims of false information, while less educated people were willing to trust government health workers.

For education, formal and informal, to result in knowledge that positively impacts health behaviours of a large number of people, we need to both raise the level of formal education by improving its access and quality and fast track health and nutrition literacy among general population.

The content of educational messages must be well founded on sound science, while taking into account the specific health needs and cultural practices of the population groups being addressed. Credible agencies and individuals must be engaged to quickly counter and contain fake news. The power of education can then be used to promote the health of populations and protect the health of individuals.

Educational institutions and students

Educational institutions can transform students into agents of health promotion. School and college students who are sensitised to health issues and motivated to adopt healthy behaviours at the personal level can also become change agents in the family, neighbourhood and the wider community.

Health-promoting schools begin by changing their own environment, by ensuring clean water, good sanitation, adequate ventilation, playgrounds, ban on use of tobacco products (by students and school personnel) and by providing healthy food choices and beverages in school meals and cafeteria.

An educated and engaged younger generation can power health transformation in the country. There are several examples, from different countries, of young persons from schools and colleges leading movements for environmental protection, access to medicines, tobacco control, road safety and gender equity. […]

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Julian Tudor Hart proposed the Inverse Care Law in 1971. The law, as originally stated, reads: ‘The availability of good medical care tends to vary inversely with the need for it in the population served. He went [on] to explain that this law ‘operates more completely where medical care is exposed to market forces, and less so where such exposure is reduced.’

He declared that when healthcare becomes a commodity, rich people get lots of it and poor people do not get any of it.

It has been clearly shown, in studies conducted across many countries, that healthcare available to poorer sections of the community is poor in quality and also frequently comes at an unaffordable price.

The poor have lower educational levels, with inadequate health literacy. This diminishes the quality of self-care, while impeding health-seeking behaviours. The poor cannot purchase good quality healthcare if they are not protected by a system of universal health coverage.

Even if free care is available, social prejudice against a poorly dressed person, who is unable to converse in a polished manner, often results in limited attention and suboptimal care. In contrast, the rich and other social elites expect, demand and invariably get respectful attention and good quality care from a healthcare team.

Poverty not only predisposes a person to disease but also detracts from the quality of healthcare, leaving the poor doubly disadvantaged. The preferential treatment given to the rich and social elites follows the biblical Matthew principle that ‘for unto everyone that hath shall be given, and he shall have abundance: but from that hath not, shall be taken away, even that which he hath.’

Frequently, even healthcare services provided by the government are subject to ‘elite capture’, while the poor who receive inadequate services are further impoverished.

In countries where contributory health insurance and privately purchased healthcare are the principal modes of payment for healthcare services, the poor are at great disadvantage. Poverty not only breeds ill health but also makes healthcare unaffordable.

Such systems discriminate against the poor. However, the society as a whole suffers because of the spread of infectious diseases, reduced productivity and disrupted social harmony due to addictive behaviours. While it is essential to reduce poverty, it is also necessary to ensure that health services do not discriminate against the poor.