This widely-used proverb in Marathi is cited often to show how futile it is to pursue riches. The implication is clear: Poor people with a clear conscience are healthier and lead better lives than the rich folk who spend their time amassing their fortune and suffer from poor health. Nothing could be further from the truth!
Here, we will take a look at one social stressor that has an impact on a person’s life. Until now, we have looked at stressors (stress responses) that affect particular systems for some periods of time. Unfortunately, for a majority of the population in our country, there is one stressor that cannot be eliminated or minimized and none of the stress management techniques discussed are relevant. Yes, I am talking of poverty. Page after page of this book has discussed the impact of chronic stress on different systems in the body and the horrendous things that can happen because of it.
Left unsaid was the tacit assumption that these stressors, though chronic, would eventually stop. The stress management techniques that emphasized outlets of frustration, predictability and sense of control were really applicable to a world where the individual does not face a daily struggle just to survive. A starving person in Orissa or a bonded labourer in a poor state like Bihar has no use for these stress management techniques. Their lives are filled with unpredictable events over which they have no control; they can barely make ends meet and starvation is not uncommon.
Their conditions exacerbate the effects of any additional stressors they may face— prolonged illnesses in the family, drought, flooding, or any number of factors beyond their control; mind numbing hours spent working in a field or a squalid hut doing some manual work under difficult conditions; a life spent taking orders from others, jobs lost at the first hint of trouble and always wondering if the money will last till the end of the month or even till the end of the week.
When almost your entire waking hours are spent in earning a living, it is impossible to have a hobby or some other outlet for your frustration. There is a major lack of social support—your entire family is working or trying to find some work. There is no time left to unwind, sit together with your loved ones and discuss problems. Free time, if any, is likely to be spent in fighting and drunken squabbles!
I have included this as the last chapter as none of the techniques in this book can help the poor. We have developed a system of ignoring poverty in our midst. Most of us tend not to even notice the beggars surrounding our vehicles at the traffic lights. I hope this will help in bringing home the dire effects of poverty and that the readers will show compassion and lend a helping hand to the millions of sufferers in this country.
Grinding poverty leads to a massive build-up of stress: but it is always difficult to carry out a study that will establish a direct correlation. One reason for this is that poverty comes with its hand-maiden—infectious diseases. There is one way out—for example, although considered one of the richest and technologically advanced countries, America has a dark underside. There are a number of poor people whose condition is very similar to that of the poor in many other countries.
The Americans can spend considerable resources and study the problems of associated poverty. As one of my reviewers for this book suggested in jest—the only reason to include this section in the book is that data is readily available for poverty in America. That may be partly true but the real reason is that it helps to study the poverty in a rich country because all other factors have generally been eliminated. Let me explain. Say, you study the poor in Bihar and consider their average life span.
Most of them still die from infectious diseases due to inhuman living conditions. So, you are studying the effects of a disease rather than poverty. In America, most of the infectious diseases have been eradicated; there is a minimum emergency health care available to all, hunger is non-existent and the contrast with the rest of the population is easily visible. The results can thus be directly ascribed to poverty and we can draw some useful lessons from that.
The important point to note is that those who are con-sidered ‘poor’ in America do not face the sort of deprivation as the poverty stricken in India. In fact, the poor in America have more material things and access to support systems than most people in this country. Yet, the effects of poverty are damaging. One can only imagine how bad the situation must be for the nameless, faceless, poor huddled masses in this country.
Something is killing America’s urban poor, but this is no ordinary epidemic. When diseases like AIDS, measles and polio strike, everyone’s symptoms look more or less the same, but not in this case. It seems as if the aging process in some people has accelerated. Even teenagers are afflicted with numerous health problems including asthma, diabetes and high blood pressure. Poor urban blacks have the worst health of any ethnic group in America with the possible exception of native Americans. It makes you wonder whether there is something deadly in the American experience of urban poverty itself.
The neighbourhoods where the majority of the poor live, look the same all across the country, with bricked-up abandoned buildings, vacant storefronts, broken sidewalks and empty lots with mangy grass overgrowing the ruins of old cars, machine parts and heaps of garbage. Young men in black nylon skullcaps lurk around the pay phones on street corners waiting to complete drug deals. These neighbourhoods are as segregated from the more affluent, white sections of metropolitan New York as any township in South Africa under apartheid. Living in such neighbourhoods is assumed to predispose the poor to a number of social ills, including drug abuse, truancy and the persistent joblessness that draws young people into a long cycle of crime and incarceration. Now it turns out these neighbourhoods could be destroying people’s health as well.
There are many different types of disadvantaged neigh-bourhoods in America, but poor urban minority localities seem to be especially unhealthy. Some of these neighbourhoods have the highest mortality rates in the US, but this is not, as many believe, mainly because of drug overdoses and gunshot wounds. It is because of chronic diseases—mainly diseases of adulthood that are probably not caused by viruses, bacteria or other infections and that include stroke, diabetes, kidney disease, high blood pressure and certain types of cancer.
The problems start at birth. The black infant death rate in Westchester County (about 50 miles north of New York City) is almost three times as high as the rate for the county as a whole. Black youths in Harlem, central Detroit, the south side of Chicago and Watts have the same probability of dying by age 45 as whites nationwide do by age 65, and most of this premature death is not due to violence, but illness. A third of poor black 16-year-old girls in urban areas will not reach their 65th birthdays.
Four times as many people die of diabetes in the largely black area of central Brooklyn as on the predominantly white Upper East Side of Manhattan, and one in three adults in Harlem report having high blood pressure. In 1990, two New York doctors found that so many poor African-Americans in Harlem were dying young from heart disease, cancer and cirrhosis of the liver, that men there were less likely to reach the age of 65 than men in Bangladesh.
Since the days of slavery, physicians have noted that the health of impoverished blacks is, in general, worse than that of whites. Racist doctors proposed that the reasons were genetic, and that blacks were intrinsically inferior and physically weaker than whites. But there is very little evidence that poor blacks or Hispanics are genetically predisposed to the vast majority of the afflictions from which they disproportionately suffer. As the living conditions of blacks have improved over the past century, their health improved in step; when conditions deteriorated, health deteriorated too. This has helped supporr the contention among researchers that chronic disease among minority groups is caused not by genes, but by something else.
In some ways, public health institutions in America are in the same position they were in 150 years ago. In the mid-19th century, public health boards were established to fight the great killers of the day—cholera and tuberculosis. The poor were more susceptible to these diseases then, just as they are more prone to chronic diseases now. And then, as now, the reasons were unknown. Some believed diseases were acts of God and the poor got what they deserved. If they would only drink less, go to church and stay out of brothels, they wouldn’t get sick. Others maintained that the afflictions of poverty were environmental. A stinking mass of invisible vapour, referred to as ‘miasma’, hung in the air over the slums, they claimed, and sickened those who inhaled it.
It was not until the early 1880s, when the German scientist Robert Koch looked down his microscope at swirling cholera and tuberculosis bacteria, that everyone finally agreed about what was going on. The water the poor drank was full of sewage and contained deadly cholera germs; in overcrowded tenements, the poor breathed clouds of tuberculosis bacteria. Malnourished alcoholics tended to be more susceptible to these diseases, but immoral behaviour was not their primary cause. Nor was miasma. The primary cause was germs.
There is no germ theory for chronic diseases like stroke, heart disease, diabetes and cancer. We know something about what can aggravate these diseases—diet, smoking and so on— but not enough about why they are so much more common among people who live in certain neighbourhoods, or what makes, for example, a poor person who smokes the same number of cigarettes a day as a rich person more likely to get lung cancer. Or, why several research studies show that smoking, eating, drinking and exercise habits do not fully account for why rich people are healthier than poor people. Even the lack of health care cannot entirely explain the afflictions of the poor. Many poor people lack health insurance, and those who have it are often at the mercy of overworked doctors and nurses who provide indifferent care. However, inadequate health care cannot explain why so many of them get so sick in the first place.
Clearly, we need to examine this miasma with a different kind of microscope. The best we have at the moment are theories that fall into two main schools of thought. One school holds the view that the problem has mainly to do with stress; the other holds actual deprivation responsible. These two factors are often intertwined, but the emphasis is important. The poor have enormous family obligations. While the middle-class people are able to purchase childcare and care for elderly relatives, the poor cannot. The experience of racism and discrimination in everyday life is also still very real, and very stressful. Blacks are faced with a society that institutionalizes the idea ‘that you are a menace—and that demeans you’. Nancy Krieger, a Harvard researcher, found that working-class African-Americans who said they accepted unfair treatment as a fact of life had higher blood pressure than those who challenged it.
Some social scientists call the grinding everyday stress of being poor and marginalized in America ‘weathering’, a condition not unlike the effect of exposure to wind and rain on houses. Stress is subjective, a feeling, and it means different things to different people. Many researchers involved in public health research note that stress is like the miasma that was once thought to cause cholera in 19th-century slums. ‘You can’t see it, you can’t really measure it, but it floats over certain people, especially the poor, and makes them sick.’f’weathering’ and stress have their modern-day Robert Koch, he is probably Bruce McEwen, a neuroendocrinologist at Rockefeller University in New York.
McEwen argues that stress hormones threaten the health of poor people, especially blacks and the Hispanic poor. As we have seen throughout this book, constant exposure to stress hormones impairs the immune system and damages the brain and other organs. Chronic stress also signals the body to accumulate abdominal fat around the waistline, which is more dangerous than fat that lies under the skin, or subcutaneous fat. Abdominal fat worsens many chronic health problems, including diabetes and heart disease, whereas subcutaneous fat does not.
Not everyone believes that stress is a major contributor to the health crisis among the poor. George Davey Smith, a professor of clinical epidemiology at the University of Bristol in England, believes that the poor live very stressful lives, and that racism is an everyday reality for many people. However, in his view—the second school of thought on the matter— the health crisis among the poor has more to do with living in a deprived environment.
A recent survey conducted in four regions of the US found that there were three times as many bars in poor neighbourhoods as in rich ones, and four times as many supermarkets in white neighbourhoods as in black ones. There are fewer parks in poor neighbourhoods as well, so it is more difficult to find open spaces in which to exercise, and many of them are dangerous. It was observed that 41 per cent of New York’s public elementary schools have no consistent physical education programme. Public health campaigns that tell people to ‘just say no’ to smoking, or to change their diets and starr exercising, can be cruel if they are indifferent to neighbourhood circumstances.
Many of the poor black people who are sick today grew up in the 1940s, 1950s and 1960s when many black people lived in overcrowded dwellings and were more prone than affluent whites to childhood infections. Some of these infections may have long-term effects on health. Adults, who were poor as children, even if they are not poor now, are also more prone to stroke, kidney disease and hypertensive heart disease. It is especially relevant at this point to discuss a very important study carried out on nuns as regards the effects of poverty. In this study of a group of Catholic sisters who had taken their vows in youth, the scientists found that their patterns of disease, aging, dementia and longevity itself were determined by their socio-economic status before they became nuns.
This is an incredible finding—as the sisters after taking their vows had rhe same food, shared their living quarters and led the same life. The indelible mark of poverty from their ordinary lives could not be erased and the sisters from poor families had more diseases and other problems than their compatriots who came from average households. It seems that being born to poverty carries tremendous residual, psychological, and sociological consequences even for those who have moved out of poverty.
Presumably both stress and material disadvantage are important causes of ill-health among the poor. But which is more important? And what would be the best way to address these problems? If stress is a major cause of ill-health, what interventions to alleviate it might be beneficial? On the other hand, if material disadvantage is a major cause of ill-health among the poor, then extensive changes are needed in the environment in which the poor live.
People who are not poor often casually ascribe their aches, pains and even more serious afflictions to ‘stress’, which is a far more serious problem for the poor. As we discussed in chapter 14 on stress management, one of the key principles is to have a sense of control. Poor people almost always have a complete lack of control over their lives as well as the way society and its institutions treat them.
In closing, I would like to make a sincere appeal to all the readers to do their bit to help the poor in our midst. The help can be in any form and it may be as simple as acknowledging that the beggars and the others living in our streets and below the flyovers are humans too and deserve to be treated with basic decency. If you can pause for a moment and think what it must be like to be treated with contempt by others, you will begin to get a sense for how the poor live every day. Empathy and even a small donation to any charitable institution working with the poor will go a long way in helping them.
To get the answer to the question of who won the race, we first need to get a little more technical and define what we mean by ‘win’. If we say that a win means the first team to identify and describe the chemical structure of a hormone that directs the pituitary to release some other hormone, then the winner is the Schally team. They submitted the details of a hormone that controls the way in which the pituitary regulates the thyroid hormone. In what we could call a photo finish in scientific terms, Guillemin and his team submitted a paper reaching the same conclusion almost five weeks later.
But, several months before these papers, it was Guillemin and his team that published a paper that identified the chemical structure of the hormone that indirectly regulates the thyroid release and claimed that though they had not isolated the chemical from the brain mash, it would be present in the mash. So, in effect, they were the first to find the hormone from the brain to the pituitary but they just could not separate it out from the brain mash.
I will let the reader decide the real winner of the race. Suffice it to say that the Nobel Prize committee decided to award the prize to both the scientists in recognition of their contributions to this field.