The pervasive poverty pandemic is a major threat to health and survival. History books and fiction frequently feature the tight links between poverty and health, but this ‘common knowledge’ is consistently ignored in political responses to public health challenges. Given the firmly established relationship between poverty and health inequalities, explained by the “inequitable distribution of power, money, and resources,” this neglect is astounding. Sidestepping conversations about the impacts of poverty and redistribution of wealth has serious consequences for health. Above all, the COVID-19 pandemic is a case-book example of how people living in scarcity are less likely to be protected from illness and death. Staying at home is only possible when you have a place to stay and a safe job with decent pay. Washing your hands is only possible with access to water. Seeking health care is only possible when treatment is affordable and accessible. Extreme poverty undermines all of these measures. Six months into the global pandemic, we have only seen the beginning of how COVID-19 will push even more people living on the margin into extreme poverty. These two intertwined pandemics beg the question of why poverty elimination and redistribution are not taken more seriously as global public health measures.
Last month, the outgoing UN Special Rapporteur on extreme poverty and human rights Philip Alston presented an alarming portrait of global poverty. The report ‘The parlous state of poverty eradication‘ declares that we are failing on poverty eradication. Recent attention to development and growth may be well-intended, but masks the neglected chronic poverty pandemic. According to the World Bank, the share of people living below the International Poverty Line at US$1.90 (2011 PPP) a day was reduced from 36% to 10% between 1990 and 2015. The report questions whether this observed decline represents meaningful progress when 46% of people still live on less than US$5.50 (2011 PPP) a day. In response to Alston’s report, others argue that there has been improvement also when looking at higher poverty lines, albeit to a lesser extent.
Positive narratives on poverty reduction further occlude the substantial shares of people who live below national poverty lines; in Thailand, 0% of the population live below the International Poverty Line, but 10% under the national poverty line. Similarly, the international poverty rates of 19% in South Africa and 22% in Mexico mask the national rates of 55% and 42%, respectively. Summarised, Alston’s view is that the International Poverty Line legitimises the ‘success’ of living at US$1.95 (2011 PPP) a day. This is ethically and financially problematic. Living on US$1.95 a day can rarely provide people with adequate standards of living. Extreme poverty hereby restricts people’s opportunities – both directly and indirectly – to escape illness and premature mortality, necessitating a closer examination of the social arrangements that permits these inequities.
Against this background, Alston calls for a transformed agenda against poverty, providing recommendations on universal measures, redistribution of wealth and tax justice. The disturbing portrait of extreme poverty should motivate reflection among medical and global health experts. In spite of the irrefutable relationship between poverty and health, the central role of redistribution and tax justice has too long been neglected in academic and policy discourses.
Fair and equitable taxation at a national and global level is crucial to redistribute wealth and serves as an equaliser for health. Regrettably, our initial PubMed searches for publications on poverty, redistribution, tax and health (by titles and abstracts; 1990-2020; 2015-2020) expose a neglected research agenda. A search on “tax/”taxation”/”tax system”, “health” and “poverty” received 128 hits (73 last five years) and “tax/”taxation”/”tax system”, “health” and “restrib*” got 66 hits (24 last five years). The low yet slowly increasing number of publications underscores that even if the links between poverty and health are well-known (14569 and 6177 PubMed publications the last thirty and five years, respectively), there remains a startling gap in the literature on addressing poverty.
What could explain this lack of attention? Does it reflect health research’s preoccupation with biologic and medical individual-level risks rather than population-level policies? Or does it represent a form of ‘surrender,’ where redistribution and taxation are seen as policy responses far beyond the scope of the health sector? We believe it is unfitting for the medical and public health professions to diagnose a problem only to delegate to others the task of identifying and promoting the cures. The Special Rapporteur describes how promoting domestic revenue mobilization, pro-poor fiscal policies and addressing tax avoidance can prevent and treat extreme poverty. Universal social protection is key to ensure not only wealth, but also health. While we doubt that the primary intent of policies to redistribute wealth is to improve health, these measures could be ‘best buys’ for stakeholders aiming to promote health and well-being. If not, we worry that tax, welfare and health systems alongside unfettered practices of global corporations will continue to deliver health inequalities. Global health professionals and experts, who observe, experience and study the unequal impacts of these systems, should move beyond recognising the poverty pandemic and claim a stake in the broader and inherently politicised debates on how to redress it.
Kristine Husøy Onarheim is a medical doctor, a research fellow at the Centre for Gender & Global Health, University College London and an affiliated researcher at the Bergen Centre for Ethics and Priority Setting, University of Bergen. Twitter @Krionarheim.
Unni Gopinathan is a medical doctor and senior researcher at the Cluster for Global Health, Division for Health Services, the Norwegian Institute of Public Health. Twitter @Unni_Gopinathan.
Competing interests: None declared.