XXXVII. Poverty, Gender and Health

Many people in the world are too entrapped in the throes poverty to realize that combining a sense of intellectual curiosity with social activism is even a possibility. When we Westerners (even the poorest amongst us) talk about “stress” it is at an altogether different level than that experienced by the poorest half of humanity – people forced to live on fewer than a couple of dollars a day, for whom a day of missing work may literally mean the difference between life or death, and where medical care for even serious ailments is pretty much impossible.


I got into this work for a variety of reasons that I have discussed over these entries. Early on in my career I realized that poverty is the strongest predictor of poor health and female literacy is wealth’s most important modifier. When women have financial resources they generally tend to buy clothes, food, and school supplies for their children. When men have financial resources they generally tend to buy weapons; alcohol, tobacco and other drugs; and things powered by internal combustion engines. The typically male way of using resources digs families (indeed whole societies) deeper into the depths of poverty. The female way of using resources provides a ladder out – a means of escape. There are lots of exceptions, but this is useful generalization. Really, what percentage of people who go on homicidal rampages with semi-automatic weapons are women?

Kerala, a state in South India dominated by a matrilineal system of passing resources on to the next generation, has an overall adult literacy rate of about 90% (which is considerably higher than that of South Carolina), has health indicators better than that of South Carolina, has had a freely elected communist government for all but about 5 years of the 62 years since independence (quite unlike South Carolina’s regressive political system), and average wealth (expressed as State Domestic Product) less than 10% than that of South Carolina! Now there’s common sense and efficiency for you.


In an article we published 15 years ago [Hertz E, Hebert JR, Landon J. The influence of economic factors on life expectancy, infant mortality and maternal mortality rates. Soc Sci Med 1994;39:105-114.] we showed that overall wealth predicted health outcomes, but the most interesting lesson could be learned from four “outliers” (i.e., countries whose statistics were not fully explained by the economic-epidemiologic models). Egypt and the U.S. were much worse off than expectation – and both had military budgets far higher than the world average (at that time they each spent 43% of total government expenditures on the military). Costa Rica and Sri Lanka were much better off than expectation – the former did not have (and still continues not to have) an army and Sri Lanka (at that time at least) expended very little on its military. Twenty-five years of civil war, I am sure, has taken its toll on Sri Lankan health indicators.


Also as I have mentioned before, the trends I have seen emerge over the time that I have been in this line of work are not encouraging. Oppressive regimes, especially with respect to women’s rights, have emerged in a wide belt from North Africa, through the Middle East, Western Asia, and Southeast Asia and into the Malay Peninsula and the Indonesian Archipelago. India stands as one of the few bright lights in this darkening landscape.


What does this have to do with health and cancer in particular? Plenty. Without an engaged, well-educated female population no country will be able to throw off the shackles of poverty and poor health. This applies not only to whole countries, but to any political unit – just look at the states within India: from the male-dominated, generally regressive, unhealthy North to the more egalitarian, progressive, not all that much wealthier, but much healthier South. Cancer prevention and control requires careful use of scarce resources; eating good food; avoiding tobacco; and sensible screening for many of the common cancers that are becoming a bigger problem all over the world. Societies that value women so that their voices can be heard will make decisions that can reduce overall cancer rates and lead to downstaging disease at the time of diagnosis.