by Dr. Cesar Chelala (New York) and Dr. Manuel Peña (Lima, Peru)

Poverty cannot be defined solely in terms of lack of income. A person, a family, even a nation is not deemed poor only because of low economic resources. Little or no access to health services, lack of access to safe water and adequate nutrition, illiteracy or low educational level and a distorted perception of rights and needs are also essential components of poverty.

Poverty is one of the most influential factors for ill health, and ill health — in a vicious cycle — can lead to poverty. Education has proven to be a
There is a two-way link between poverty and health. Illness impairs learning ability and quality of life, has a negative impact on productivity, and drains family savings. Poor people are more exposed to environmental risks (poor sanitation, unhealthy food, violence, and natural disasters) and less prepared to cope with them.

Because they are also less informed about the benefits of healthy lifestyles, and have less access to them as well as to quality health care, they are at greater risk of illness and disability.

Close to 1.5bn people in the world live in extreme poverty, a situation which is particularly stark in the developing world, where 80% of them live. Poor people have little or no access to qualified health services and education, and do not participate in the decisions critical to their day-to-day lives.

Those who live in extreme poverty are five times more likely to die before five years of age, and two and a half time times more likely to die between 15 and 59 than those in higher income groups. The same dramatic differences can be found with respect to maternal mortality levels and incidence of preventable diseases. Level of education in relation to health is particularly important among women. In addition, education for women is closely associated with later marriage and smaller family size.

The impact of poverty on health is largely mediated by nutrition and is expressed throughout the life span. However, nutrition and health are only somewhat responsive to mere economic growth.

Increased income alone cannot guarantee better nutrition and health because of the impact of other factors, notably education, environmental hygiene and access to health care services, which cannot necessarily be bought with increased income in the developing world.

Those living in poverty and suffering from malnutrition have an increased propensity to a host of diseases, a lower learning capacity, and an increased exposure and vulnerability to environmental risks. Poor children frequently lack stimuli critical to growth and development.

The unrelenting stresses in the struggle for survival do not allow poor families to fully appreciate the importance of stimulation and nurture, and even if they do the opportunity to provide these stimuli.

Experiences in several countries have demonstrated the power of education to increase the nutritional levels and the health status of the poor. In urban India, for example, it has been found that the mortality rate among the children of educated women is almost half than that of children of uneducated women.

In the Philippines, it has been shown that primary education among mothers reduces the risks of child mortality by half, and secondary education reduces that risk by a factor of three.

Several strategies can be used to improve the access of mothers and children to educational opportunities as a way of improving their health status. At the national level governments, particularly in developing countries, have to establish education — including the education of the parents — as a priority, and provide necessary resources and support.

Interventions should be targeted to vulnerable groups such as those with lower income or with less access to adequate food.

At the international level, lending institutions have to implement debt-reduction policies for those countries willing to provide increased resources for basic education.

Although an important goal is to reduce economic inequity to improve the health status of populations, emphasis on education can provide substantial benefits in the health status of populations even before reducing the economic gap between the rich and the poor.

Dr. Cesar Chelala is a public health consultant for several international organizations. Dr. Manuel Peña is the Pan American Health Organization representative in Peru.