Movimiento de masas de tierras

“Poverty is the world biggest killer of people” (WHO 1995). Perhaps this is an uncompromising statement however it is still valid in many developing nations as it is one of the main underlying problems that they face. Quite a lot of the problems faced by the developing nations could either be directly or indirectly linked with the levels of poverty each country has. Therefore it is critical that countries take measures to reduce the levels of poverty and develop strategies to ensure that conditions are not created where poverty

reaches unmanageable levels, which could then overwhelm major efforts to reduce disease. The statement below quite well depicts how interwoven poverty and health are but it may appear a bit far-fetched. However to an individual in extreme poverty it has great relevance.

“Poverty is the main reason why babies are not vaccinated, why clean water and sanitation are not provided, why curative drugs and other treatments are unavailable and why mothers die in childbirth. It is the underlying cause of reduced life expectancy, handicap, disability and starvation. Poverty is a major contributor to mental illness, stress, suicide, family disintegration and substance abuse. Every year in the developing world 12.2 million children under 5 years die, most of them from causes, which could be prevented for just a few US cents per child. They die largely because of world indifference, but most of all they die because they are poor”. WHO 1995.

Historically around the time of independence it was estimated that over 50% of the population lived in extreme poverty but over the years India has been successful in reducing the percentage of people living in poverty (World Bank 2004). The estimated levels of poverty in India at present (2000 to 2010) vary according to the various agencies as a result of the different variables they use to measure the levels of poverty. Conservative estimates indicate that about 26% (Mehta et al 2003) of the population live below the poverty line which is defined by those who earn less than a USA dollar a day. However estimates by the Department For International Development UK (DFID 2004) show it to be about 35% whilst other estimates by GOI (NHP 2002) put the figure around 44% of the population. Although there is quite a large variation in these estimates there should be no doubt that poverty and its ill effects have widespread ramifications on the public particularly in terms of health. The seriousness of poverty in India can be better understood if a different variable was considered to categorise those who are poor. This can be done if one took into account the number of people who earn 2 US dollars or less a day the statistics indicate about 80% of the population fit into this category (Earth Trends 2001). Those considered marginally above the poverty line i.e. who earn more than $1 but less than or equal to $2 a day, also represent such a large segment of the population and their struggle for survival is equally arduous but perhaps slightly better off than those who live in extreme poverty. Numerous studies have been conducted on the relationship of poverty and health and have shown that those having a low socioeconomic status have far worse health indicators and their chances of living healthily is

less likely than those with better socioeconomic prospects (Heuveline et al 2002, Mehta et al 2003, WRI 2001). A report by the International Fund for Agricultural Development (IFAD) in 2001 show that about 1.2 billion people around the world live below the poverty line. Taking this fact on board one should realise that in between 20% and 35% of these people living below the poverty line actually live in India. Notwithstanding the fact that at present India is making great progress in virtually all levels of trade and development, and it is perceived by many developed nations that it is in line to become one of the two great economic hubs of that region, the other nation being China. However this surge in economic development appears to be enjoyed exclusively by a few whilst large segments of the population are not associated with this phenomenon and find they are unable to rid themselves from the shackles of poverty, hence benefiting fully from this apparent prosperity seems to be elusive.

The elites and an emerging but large middle class are mainly enjoying these apparent levels of successes, whereas those living below the poverty line or those who are just marginally above this measure find daily survival and existence an uphill task to fulfil. Unless successful measures are introduced as opposed to egalitarian rhetoric and programmes that do very little to alleviate problems caused by poverty, the perceived levels of economic success that India claims and also the high levels of progress it is accredited with will always be marred by the fact that substantial portions of its population still live in grinding poverty and suffer all the ill effects associated with poverty.

Quite often poverty poses some very obvious problems for which relatively easy solutions can be found. For example those suffering from malnutrition, the obvious answer is to take adequate amounts of food however if one cannot afford the price of food because of poverty, it will be a perplexing problem to solve. Of course it would be incorrect to say that GOI and the state governments are not doing anything to tackle the problem of poverty and in fact there are numerous ongoing schemes that have been adopted to reduce the affect of poverty. Schemes such as the Public Distribution System (PDS) of subsidised food grains and domestic fuel have a direct impact on the majority of people living below the poverty line. The PDS has achieved its network virtually throughout India as almost all the villages have a distribution centre. One of the positive effects of the PDS network is that India does not suffer famines to the extent it did historically as this network is able to deliver food grains quite effectively throughout India. The PDS initially offered all the citizens of the country

some amounts of products on this system but those who were classified to be very poor were given a higher quota of products and they also got a higher level of subsidy. Gradually the concession to all the citizens was removed and the PDS concentrated mainly on those who live marginally above the poverty line and those that live below this level. A higher subsidy is paid on those living below the poverty line so that they can access food grains and domestic fuel at affordable price. However the desired effect of the PDS has not yet reduced poverty to manageable levels in most of the country. This is because PDS has been plagued by malfunction caused usually by systemic deficiencies like poor storage facilities and transport, pilferage by distribution agents and endemic corruption that virtually bedevils the entire scheme.

In this section I do not intend to explore in detail why there is poverty or the extreme effects it has on people but to accept that significant portions of the population in Bidar live more or less under or just above the poverty line. Typically the section of population represented to be poor and marginalised in India are the schedule castes, schedule tribes, other lower castes and some who belong to minority religious groups. These people are the ones who tend to need healthcare much more than others (refer to table 2) and their case is much more compelling as episodes of ill health usually have a detrimental effect on them because they do not have the option of mobilizing enough financial resource to access better or higher levels of healthcare. Neither do they have the opportunity to earn substantially to use the excess income as leverage when episodes of ill health come along. The affluent on the other hand have a choice and can access both public and private healthcare providers according to their status and the levels of income they have. However most of the poor people mainly depend on their physical wellbeing to earn a living and any major episodes of ill health could put them out of work and have a devastating effect on their income insidiously leading them downward on a spiral of debt and poverty. My thesis intends to highlight how these wide gaps between those who have and do not have the means, could be bridged by an effective provision of healthcare, which would lead to levelling out the health inequalities that exist in between various social groups.

The states of Bihar, Uttar Pradesh, Madhya Pradesh, Orissa, and Rajasthan are considered to have the lowest levels of income in India. Poverty within these States ranges from an estimated 50% to 66% of the population living below the poverty line and over half of India’s poor people live in these states (Mehta et al 2003). Karnataka State is not normally

considered a state where there are high levels of poverty existing. However the northern districts of Karnataka have the peculiarity of being backward and less developed thus sharing some similar indicators (particularly those relating to poverty) with states that have high levels of poverty. Bidar being one of the least developed districts in Karnataka State has some conditions that are rife with the potential to cause serious health problems. Therefore the need for a proper provision of healthcare is urgent and the authorities should focus on all the programmes that alleviate the problems of ill health faced by the public. The challenges faced by the health authorities resolving problems inherently caused by high levels of poverty in the population appear to lead to a vicious cycle, which eventually increases, and over burdens the existing healthcare provisions.

“Pockets of poverty and deprivation, therefore, persist giving rise to three simultaneous burdens for South Asia and much of the rest of the developing world: continuing communicable diseases, increasing burden of chronic diseases, and increasing demand for both primary and tertiary levels of health care services”. (Anwar and Tahir 2002) p.151.

Anwar highlights that poverty can cause perplexing problems for those who experience it and also for those with the responsibility of dealing with reducing the problems of poverty. The only way to get out of this situation for healthcare providers is by ensuring that the positive effects of interventions by various government agencies and their initiatives, and also non- government bodies that intend to reduce the levels of poverty in the country are not forfeited by allowing episodes of ill health to have a debilitating effect on people, consequentially allowing them to slide back into poverty.

Alcoholism.

Historically India tried to adopt a Gandhian ideology of teetotal dry state. However the substantial revenue from the sale of alcohol as opposed to the high cost of enforcing complete prohibition made it virtually irresistible for states not to allow the sale of alcohol. Apart from Gujarat State (the state in which Gandhi was born) every other state in India has allowed alcohol sales although there were instances in history where States did experiment with total prohibition but it never seemed to persist for long periods of time. As excise revenue from the sale of alcohol is based on a percentage basis hence it was aggressively promoted by the

liquor industry, which in turn benefited the states coffers tremendously. The growth in this industry and also high levels of consumption has helped this industry to appear very lucrative and has created vast sums of income for those who own this industry and they have gained the status of liquor barons. These barons have tended to wield great influence over governments because of the wealth and power they have gained. It is alleged in Karnataka that these barons, more commonly known as the liquor lobby, virtually bankroll political parties and politicians to ensure that nothing adverse to their interest ever takes place. The significance of the liquor lobby can be clearly seen by the amounts of revenue they generate in Karnataka. Karnataka can be described as one of the states with superfluous amounts of alcohol where 25% of the states revenue comes from the sale of alcohol (DH 2006). Therefore Karnataka is heavily dependent on the revenues from this industry. It might be suggested that one of the consequences of having a large alcohol industry is that it is becoming a state where there is a growing population of alcoholic addiction and high consumption of alcohol. According to the second National Family Health Survey 1998-99 (NFHS-II) it shows that about 18.2% of urban males and 22.5% of rural males regularly drink alcohol. It must be noted that men mainly consume alcohol in India, as the same NFHS-II survey showed that only 0.1% of urban and 0.2% of rural women drink. Other more recent studies have indicated that in between 10% to 60% of the male population consume alcohol of which about 1.2% becomes dependant on alcohol (Gururaj et al 2005). Although there is not an up-to-date database to confirm the exact number of people who regularly use alcohol or are addicted to it, it would not be farfetched to suggest that in Karnataka it would be an inherent factor that within this state alcohol related problems affect large portions of the population

Legal retail sales of alcohol in India are mainly sold in 3 forms 1. Indian Made Liquor (IML) i.e. whisky, brandy, rum etc, 2. Arrack (rectified spirit fit for consumption usually having a high % of alcohol), and 3. Alcoholic spirits extracted from palm trees. IML is made mainly made and priced to cater for those who can afford such drinks but there is quite a wide range of quality hence prices also vary and some brands of poor quality IML are relatively cheap and some poor people and those who are marginally above the poverty line can afford to drink such products. However most poor people are left with the choice of either drinking arrack or palm sap based alcohol. Palm sap is only sold in areas where these palms grow hence most of the poor people left to drink arrack.

The significance of drinking arrack and the ill effects it has on the public may be perceived along the following lines. Historically poor people used to be able to drink home brewed or locally brewed alcoholic drinks, which tended to cost Rupees (Rs) 1or2 for a bottle consisting of 650ml to 750ml. It did not have a significant economic impact on the individual as only a small portion of his or her income was spent indulging in this habit. However it used to be quite common to see occasional tragedies where unscrupulous brewers mixed methyl alcohol (industrial alcohol) instead of ethyl alcohol, which caused blindness and death in the extreme case. Therefore the government took a stringent and a highhanded approach to stop all individuals / local factories who brewed alcohol and introduced arrack produced by the state presently priced about Rs10 for a sachet containing 180ml. Therefore those who regularly drink often find themselves drinking 4 or 5 sachets of arrack a day. The government mainly justifies the high price of arrack to use it as a deterrent. However in India a person earning about Rs 45 a day (average exchange rate for one US dollar) or even Rs 90 who consumes arrack in large quantities regularly will find that the economic impact will be very severe. As men are the main breadwinners hence it is inevitably their families suffer because there is very little income spared for the family to survive on and to meet the rest of their needs. The scale of arrack consumption can be put into perspective whilst considering that over half of the excise revenue in Karnataka State comes from the sale of arrack (DH 2006). Presently there is a policy to have an arrack shop to cater for a population of 3000 people but there is evidence that the liquor lobby / arrack contractors want to enhance their sales by putting pressure on the government to permit arrack shops for a population of 1500 people (DH2006). Perhaps it should not be surprising to see this happen in the near future as the government has a tendency to succumb to the liquor lobby and rake-off the revenues created by the efficient supply18 of arrack throughout the state. It might be suggested that the high levels of consumption of arrack and its unhindered aggressive sales is one of the key factors that can be linked irrefutably to the cause of people’s suffering from poverty, deprivation and ill health.

18

Arrack contractors do the supplying of arrack throughout the state. They are extremely efficient in the sense that they are able to supply and collect the revenues from arrack sales. They are able to cater for the demand even in remote and inaccessible areas. For example if stocks of arrack run out at 10pm by 6am the stocks are

4.

Concluding discussion.

In this chapter I intended to highlight why there is a need for an efficient delivery of healthcare in Bidar district. Bidar, having the status of a less developed district with a large rural population mainly living under the grip of abject poverty, cannot be helped by a poorly functioning healthcare system. The threat of prevailing epidemics, endemic diseases and numerous health problems suffered by the people is serious. Of course the government will need to prioritise and ensure that the most vulnerable in society can access and benefit from an optimal provision of healthcare. At present the public healthcare network appears to function at optimal levels only on an ad-hoc basis especially when there is a drive to immunise or when diseases reach epidemic proportions. However whilst attempting to deliver healthcare on a sustainable, routine and regular level it appears not to be fully in control and is just superficially trying to resolve major health problems. Is this because at present they do not have the financial, technical and human resources or is it that there is a lot of apathy and the people do not have the powers or know-how to resolve the problems they face? The answer is a mix of all these factors. However at present countries like India and states like Karnataka cannot deny that they face major challenges enabling adequate financial adjustments to be made available to invest more into the provision of healthcare. The reason I