Poverty-Disease Nexus

Diseases associated with poverty account for 45% of the global disease burden in the poorest countries.

The recent public debate about poverty has focused on the economic dimensions with little or no discussion on health, which is one of the dimensions of poverty.

Poverty begets disease and some diseases beget poverty.

Poverty Begets Disease

A significant proportion of illnesses in the poor are entirely avoidable or treatable with existing medicines or interventions. Most of the disease burden in the poor has its roots in the consequences of poverty, such as poor nutrition, air pollution, and lack of access to shelter, clean water, sanitation and health education.

The World Health Organization (WHO) estimates that diseases associated with poverty account for 45 per cent of the global disease burden in the poorest countries with about 1.2 billion people, i.e. about 15 per cent of the world’s population living in extreme poverty (less than US$1 daily). However, nearly all of these deaths are either treatable with existing medicines or preventable initially.

Almost all the infectious diseases affecting the poor like tuberculosis, HIV/AIDS, malaria, pneumonia, measles and diarrhoeas, which is the panorama of poverty-related diseases, are preventable and treatable. It is estimated that 88 per cent of child diarrhoeas, 91 per cent of malaria and up to 100 per cent of childhood illness, such as measles and tetanus, can be prevented among children with existing treatments.

Malnutrition accentuates the poverty-related diseases. It is cognisant that the Global Nutrition report 2018 highlighted the problem in the urban poor in the Klang Valley, which the Unicef representative stated that “obesity, stunting and anaemia in Malaysia is a growing public health emergency – and needs to be treated as such.”

There is a substantial interplay of poverty-related diseases. For example, tuberculosis, HIV/ AIDS and malnutrition are dynamically linked with each other and with poverty itself.

Some Diseases Beget Poverty

According to WHO, “a household has catastrophic health expenditure (“CHE”) when its out-of-pocket health payments equal or exceed 40 per cent of its non-subsistence expenditure, or what is called its capacity to pay.” CHE is associated with some households having to borrow money or sell assets to finance their healthcare; earning less due to deteriorated health condition(s); are impoverished after paying for healthcare services; and some households who are already below the poverty line become even poorer due to healthcare payments.

The reports of CHE in Malaysia are disturbing.

A study by a multi-institution team reported that “coverage for catastrophically costly treatments is uneven and inequitable in Malaysia, despite most of these are affordable. Decisions on coverage are driven by political-economic consideration.” (1)

An ASEAN study reported that the proportion of previously solvent patients who experienced economic hardship following a cancer diagnosis was highest in Malaysia (45 per cent) and Indonesia (42 per cent) and lowest in Thailand (16 per cent). (2)

Significant numbers of cancer patients face financial difficulties which even impact on their treatment.

A study of patients hospitalised at the National Heart Institute (“IJN”) reported that the economic impact of ischaemic heart disease (“IHD”) in Malaysia “was considerable and the prospect of economic hardship likely to persist over the years due to the long-standing nature of IHD.” (3)

Social Dimension

Humans are, by nature, optimistic, even when there is no basis. For example, everyone expects to live longer and healthier, underestimate failures in relationships, and overestimate prospects of getting a job.

Poverty is littered with deprivations and not just income deprivation.

The poor lose their motivation to escape the shackles of poverty because of the daily fight for survival. The absence of a way out of the abyss leads to feelings of helplessness which grows on the person and sustains the poverty-disease nexus. This optimism deprivation leads to the depression that overwhelms the person, adds to the income and resource deprivation and, finally, does the person in. Those who do not suffer from optimism-deprivation are the ones who manage to break free from the shackles of the poverty-disease nexus.

Poverty and disease are intertwined in a vicious downward spiral, each aiding and abetting the other. Poverty is an entrenched consequence and cause of ill health. Poverty-related diseases increase poverty and poverty, in turn, increases the likelihood of poverty-related diseases. The hapless person is often sucked into a vortex with no recovery in sight. The callousness of the powerful and the distanced “haves” seal the fate of the victims.

The social dimension of poverty has been stated by the United Nations High Commissioner for Human Rights “…no social phenomenon is as comprehensive in its assault on human rights as poverty. Poverty erodes or nullifies economic and social rights such as the right to health, adequate housing, food and safe water, and the right to education.”

Recalibrating Poverty Measurement

The reports from United Nations (“UN”) Special Rapporteurs on extreme poverty and human rights; and on human rights to water and sanitation are wake-up calls for everyone.

The UN Special Rapporteur on extreme poverty and human rights stated in his report on 23 August 2019, that the “mainstream narrative that poverty is largely confined to small numbers in rural areas and indigenous peoples has to be discarded” and that Malaysia has declared “victory over poverty without having actually achieved it.”

The report stated that “national poverty line is not consistent with the cost of living or household income” and “also bears little resemblance to actual household need or realities on the ground.” “The illusion of poverty eradication has also been maintained in part by excluding vast numbers of people from Malaysia’s official calculations and analyses.”

The report quoted data from the Khazanah Research Institute, which found in 2016 that “a relative poverty measure of 60 per cent of median income would show 22.2 per cent of households in poverty”; and Unicef which found in 2019 that a relative poverty measure similar to that adopted by most OECD countries would place around 16 per cent of the population in poverty.”

This report has stimulated much public debate. It is only logical to endorse the predominant view that the poverty measurements have to be recalibrated just as many countries with similar income status as Malaysia have done so.

The UN Special Rapporteur on human rights to water and sanitation reported in 2018 that several segments of the population, i.e. Orang Asli; rural populations; communities affected by mega projects or living in informal settlements; undocumented children in alternative educational facilities; refugees and asylum seekers; prisoners and detainees; and transgender and gender non-conforming persons still lacked access to water and sanitation services.

There is no cogent reason to argue against the recommendations as water and sanitation are critical to human health.

Irrespective of a person’s income, the battle against poverty-related and lifestyle diseases is the same. The fight is against distress, disability and premature death; against exploitation and the callousness of the powerful; and for human development and the right to health.

“Overcoming poverty is not a gesture of charity. It is an act of justice. It is the protection of a fundamental human right, the right to dignity and a decent life.”

Nelson Mandela


  1. The elephant in the room – Universal coverage for costly treatments in an upper middle income country. 9 November 2017
  2. Policy and priorities for national cancer control planning in low and middle income countries: Lessons from ASEAN Costs in oncology prospective cohort study. European Journal of Cancer. 6 March 2017 Volume 74, Pages 26-37
  3. Does tax-based health financing offer protection from financial catastrophe? Findings from a household economic impact survey of ischaemic heart disease in Malaysia. International Health, Volume 9, Issue 1, 1 January 2017, 29–35

Dr Milton Lum is a past President of the Federation of Private Medical Practitioners Associations, Malaysia and the Malaysian Medical Association. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organization the writer is associated with.

  • This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.

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