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Poverty and health policies: Listening to the poor

SABINA FAIZ RASHID
If we truly want to see improvements in the health of poor women and men in Bangladesh, we need a more radical and broader based approach to health, where social and economic justice need to be an integral part of medicine and public health interventions. To acknowledge the role of social and political-economic factors in health is critical in health sector reform and an inadequate recognition can drive any future reform to failure and further misspent resources.****
DR. Rounaq Jahan and Dr. Zakir Husain's discussions on health sector reform has prompted me to add another dimension to this debate -- the experiences of the poor in Bangladesh. The poor whose lives are directly affected by various health polices, but who tend to have very little say in how we can better meet their needs. Dr. Husain's article emphasises the need for an "open forum robust and representative ... a forum that articulates and advocates consumer's concerns." Time and time again we speak of the need for more evidence based health policy and programming where more diverse voices should be heard. It is unfortunate that after 30+ years and the expenditure of hundreds of millions of dollars in health interventions into Bangladesh, the overall health of poor women, pregnant and nursing mothers and infants remains disappointing with little significant improvements. Having recently worked in urban slums for a period of 15 months, I would like to share how poverty (increasingly a global as well as local process) contributes to particular life conditions for the poor and critically shapes their health experiences and practices.
The assumption often among policymakers is that mere provision of health services and better choices will improve health of the poor. However, throughout my fieldwork, i was confronted by overwhelming structural and social inequalities which have led to high unemployment, crime, widespread substance abuse and the breakdown of family networks and marital relations in slums; all of which critically impact on poor women's lives and reproductive health. Acute poverty and competition over scarce resources in slums force many poor married adolescent and older women to tolerate bad marriages, abuse, forced and unsafe sex, multiple pregnancies, and coerced abortions. Poor women construct a "political economy of the body" in their reproductive and sexual health negotiations, often at a cost to their bodies and health. The lives of poor women and men in slums are embedded in conditions that allow for little to no choice. There are disabling structures that leave both poor men and especially women with no alternatives and little agency to change their position. For the poor, health cannot be separated from social and political -- economic conditions of everyday life. While health is a priority for us, it is a luxury for the poor, whose lives are plagued by multiple oppressions and social injustices.
To illustrate my point, let me share with you a case study of a typical few weeks in a slum woman's life. Farida is 16 years old, married and has a 10-month-old baby boy. When the government forcibly evicted them from their slum, Farida and her family moved into her uncle's home. Like most slum homes, her room was no bigger than 30 square feet, tiny, damp and dark. There was a torn sheet on the bed and her baby boy sat on the edge of the bed crying. Farida informed me that she was three months pregnant, anxious, and tense. She worried about her husband Sayed who does not have a steady job. She used to work in a garment factory but had not been paid for few months as the factory had shut down.
Following the September 11 attacks in the United States, there was a world recession and the RMG sector was badly affected in Bangladesh. Farida's brother-in-law promised to help them financially but was facing difficulties himself, having recently lost his job due to the ban on three-stroke baby taxis. Farida's uncle threatened to evict them because they were unable to pay rent. Farida and Sayed discussed her pregnancy and although they were both keen to have another child, this was not the best time. A few days later we found out that Farida had a crude abortion and was bleeding profusely. With the help of a traditional healer, she had inserted a (plant) root into herself. They rushed to the pharmacy and bought some medicines to control her fever and bleeding. Farida bled for 10 days before her bleeding stopped.
She decided to have an (illegal) abortion because monetarily it cost her nothing. A termination from a clinic would have cost about Taka 400, money they did not have and if they did, they could not afford to spend. They needed money to meet their basic needs -- food and rent. As she explained: "To treat this will cost me money. Will i spend money on treatment or will i spend whatever money i have to buy food? i think the money spent on myself will be better used to buy food for all of us for three days. What options do i have? My husband is unemployed and i have a baby now. We have to eat!" A few weeks later her baby fell sick with severe diarrhoea and fever and they had to rush to a nearby hospital for treatment. Farida borrowed Taka 2000 from her elder brother for the treatment. Her husband, who had recently found work as a labourer, would now have to work for more than two months to repay the loan, pushing them further into a cycle of debt, poverty, and increased misery.
Farida's experiences are typical of the countless stories i heard and documented while working in the slums. Unable to afford housing, these families live in shack settlements in the worst, most congested and unhygienic conditions, with unsafe drinking water, poor sanitation, and overflowing sewage. They live in constant fear of eviction. Poorly skilled and uneducated, they cope with erratic employment opportunities, with most families never having enough assets or cash to save or plan for the future, as they struggle each day to survive. Farida's life raises many important questions: what do we mean by health experiences or even health seeking behaviour when we look at the lives of the poor? Can we separate health or even reproductive health experiences from other aspects of their lives, the material, social, and political-economic? How do the broader macro and micro factors affect health experiences and behaviour? What multiple effects might poverty have on the poor and their health experiences?
Farida's life situation highlights the need to understand the wider structural and political economic inequalities in which the lives of the poor are embedded, which sculpt particular health experiences. in Bangladesh, health interventions implicitly follow biomedical definitions of health and focus on symptoms and treatment rather than more holistic approaches to causes of illness. Universal education in public health and biology and the availability of Western medical care are seen as preferred forms of intervention to improve the health situation of the country.
However, in the context of Bangladesh, where a majority of the population live in severe poverty, it is critical not to ignore the broader
political, social and economic processes that contribute to certain life conditions, and adverse health experiences. While better and more sensitive health services will no doubt ease the suffering of the poor, the fundamental constraints to improving their lives and health of the poor are structural and social inequalities, which force them to remain an underclass, unable to realise their health potential. If we truly want to see improvements in the health of poor women and men in Bangladesh, we need a more radical and broader based approach to health, where social and economic justice need to be an integral part of medicine and public health interventions. To acknowledge the role of social and political-economic factors in health is critical in health sector reform and an inadequate recognition can drive any future reform to failure and further misspent resources.
Sabina Faiz Rashid is a medical anthropologist and recently submitted her PhD at The Australian National University.