“Health is a universal human aspiration and a basic human need. The development of society, rich or poor, can be judged by the quality of its population’s health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage due to ill-health. Health equity is central to this premise.
Strengthening health equity—globally and within countries—means going beyond contemporary concentration on the immediate causes of disease to the ‘causes of the causes’—the fundamental structures of social hierarchy and the socially determined conditions these create in which people grow, live, work, and age. The time for action is now, not just because better health makes economic sense, but because it is right and just”. Professor Sir Michael Marmot, Interim Statement of the Commission on Social Determinants of Health As Professor Malcolm Marmot clearly states, good health is desired and required by all.
Under ideal conditions, each and every member of society, around the globe, would either enjoy good health, or at least have access to facilities which would enable him to better his health condition. However, the rise in the global burden of diseases clearly indicates that the current situation is light years away from this ideal situation. South Asia, home to a quarter of the world’s population, is a glaring example of the dismal current scenario. Defining Health and Medicine According to the World Health Organization (WHO), health is a state of complete well-being: physical, mental, and emotional.
Therefore, good health encompasses more than being disease free, and depends upon a healthy environment and a stable mind. Medicine is the social institution that diagnoses, treats, and prevents disease. 1 To do so, Medicine depends upon most other sciences—including life and earth sciences, chemistry, physics, and engineering. Popular belief dictates that science alone determines illness, but the sociological view points out that diseases and illnesses are also shaped by social, cultural and environmental factors. The study of sociology assumes that a well-functioning society depends upon healthy people and upon controlling illness.
Diseases predominant in South Asian Countries Communicable Diseases Inhabitants of South Asian Countries mainly suffer from communicable diseases, where the principal causes of death are respiratory infections (Tuberculosis), HIV/AIDS, infections at birth, diarrhoeal disease and tropical diseases such as malaria, typhoid, etc. Non Communicable Diseases Though communicable diseases still remain as the major concern, South Asians are now also suffering from non-communicable diseases such as heart attacks, strokes, hypertensive heart diseases, etc.
The onset of these diseases, occurring primarily in the urban regions, are signified by high and rising rates of overweight, central obesity, diabetes, high blood pressure, etc. Such trends also exist in rural populations but are lower in magnitude. Each of the Communicable and Non Communicable diseases which are predominant in South Asia has been shaped by the social structures of the individual countries, along with cultural norms and environmental conditions. Social Factors behind Diseases Poverty:
In South Asia, approximately half the population lives below the poverty line and has limited access to health care. Those living below the poverty line, or even in the rural areas, are usually more susceptible to diseases because they often cannot provide adequate preventive and curative health services. Adding to this problem is the fact that poor individuals and households cannot move from unhealthy surroundings, buy enough food or use the services that exist. Poor communities usually do not have the political power needed to get better services.
One of the leading causes of death in the least developed South Asian regions is the infectious disease tuberculosis (TB). Poverty and TB create a vicious cycle. Poorer populations are twice as likely to have TB, three times less likely to access care for TB, four times less likely to complete TB treatment and five times more likely to incur impoverishing payments for TB care2. In an effort to cope with the disease, people may decrease food intake, sell assets, borrow, withdraw children from school, leave their families or delay seeking care.
There may be direct impact in the form of income loss, stigmatization and homelessness. Poor housing, overcrowding, malnutrition and risky behaviour also play important roles. Tuberculosis is the single leading cause of death among women of reproductive age. One of the leading causes of malnutrition and ill health in South Asia is ‘food poverty’. Over 350 million in China and India alone do not have access to basic nutrition requirements. 13 Malnutrition increases the risk of infection and infectious diseases, and is one of the biggest contributors to child mortaility, according to WHO.
Prostitution and Sex Tourism: HIV/AIDS is deeply rooted in social structures and institutions, making it a particularly important disease for studying the social aspects of health. Across South Asia, prostitution exists in different forms, including ‘red light areas’ and brothel based prostitution. The region is home to a huge number of red light areas in big cities and medium towns, in transit business points on routes of business, as well as close to major industrial centres, and along highways and the borders, where there is military or paramilitary presence.
Some of the largest red light areas in the region are Sonagachhi in Kolkata, GB Road in Delhi, Kamathipura in Mumbai, Budhwar Peth in Pune, Heera Mandi in Lahore, Patuakhali in Barisal, in Jessore and Khulna3. Sex workers are forced to enter into this occupation due to limited economic opportunities for women, leaving prostitution as the highest paying job available to many of the women of Southeast Asia. The health costs, however, far outweigh the economic benefits. Sex workers are one of the major sections which become infected with HIV, the virus that causes AIDS.
For instance, blood tests among commercial sex workers in Bombay have shown more than half of them are infected with HIV12. The idea of creating designated areas for sex tourism in Asia dates back at least as far as pre-Communist China, where brothel trains, given the euphemism of ‘comfort waggons’ were a long accepted part of social life. This practice is present till today, where countries like Thailand have even legalized prostitution due to the nation’s economic benefits. While many South Asian countries have enefited from the tourist presence and the resulting foreign exchange, the women who actually put themselves out for their countries development are one of the major ones to have become infected with HIV, contributing to increasing rates of HIV/AIDS. Migration Patterns: Rural-urban migration is a common phenomenon in South Asia, where endemic poverty in the country side forces people to move to the cities in search of livelihood. Migration also takes place because of frequent natural disasters, as is the case in Bangladesh, Pakistan and West Bengal, or due to conflict situations, such as those prevailing in Nepal due to Maoist Rebels.
The migrants live in slums and squatter colonies, where living conditions are abysmal. Slum dwellers are therefore prone to many water-borne and air borne diseases such as typhoid, diarrhoea, etc. The main victims of Rural-Urban Migration, however, are street children in South Asia. According to UNICEF, there are about 25 million street children in Asia. It is an extended phenomenon all over South Asia affecting growing cities undergoing an influx of migration from the countryside or even from neighbouring countries. It is estimated that there are over 600000 street children in Bangladesh, 75% of who live in the capital city of Dhaka.
Additionally, there are 42500 street children in Pakistan, more than 5000 street children in Nepal and more than 11 million of them in India, of which at least 100000 are found in Kolkata. Children move out of their families to the streets or railways platforms to decipher ways to earn money where employment opportunities are available. While the children are already victims of poor mental health, given that a great number of them have left their families due to domestic violence or family dysfunction, their physical health is also affected in the cities.
This is because the street children clearly lack access to basic facilities and experience physical, emotional and sexual abuse and exploitation, perpetrated by the police, the hawkers, the vendors and other adults who poach on such vulnerable targets for prostitution and trafficking. Most of them experience early and unprotected sex and are vulnerable to HIV/AIDS and substance abuse. Urbanization and Income Disparities: South Asia is also experiencing urbanisation, and this growth in urbanization is one of the primary reasons behind the inception of non-communicable diseases in this region.
This is because urbanization has strong connections to two basic factors which affect health adversely: longer working hours leading to high levels of stress, and ‘food plenty’ which also causes health problems such as obesity. Urbanization, however, is assisted with widening income disparities. At its simplest, urbanization has led to the rich getting richer, while the poor will got poorer. While the economic implications of this factor are alarming enough, its impact on health of the rural population is also a major cause for concern.
While the poor already have minimal access to health care facilities, this decline in their social and economic condition makes them even more vulnerable to diseases. Gender discrimination: Gender inequality is a strong determinant of health. Gender discrimination leads to differential access to food and medical care, discrimination against girls in nurturing and care, the inability of girls to attend school, sexual abuse at the workplace and other forms of sexual harassment which affect the health of women.
The problem of gender discrimination is particularly reflected in the comparatively lower enrolment in Primary schools for girls. In South Asia, only 83% of girls are enrolled in Primary Schools, compared to 90% of boys11. While there is a narrowing gap at secondary and tertiary levels, a significant proportion of girls still drop out after primary schooling. Since a solid education is one of the prerequisites of good health, low enrolment at the primary level of schooling, along with high dropout rates, leads to inadequate education of the female population, by and large.
This in turn makes them more vulnerable to health hazards. In addition, women in South Asia, particularly in India and Bangladesh, are vulnerable to different forms of violence over their life cycle. This includes battering, coerced pregnancy and mass rape in conflict situations, all of which severely affect the mental and physical health of women. Societies also place a greater stigma when women contract a disease compared to men. This in turn prevents women from seeking medical help. This kind of cycle is particularly true in the case of two diseases: TB and AIDS.
Rates of TB are generally high in South-East Asia, with higher female mortality rates compared to other regions. The stigma of TB, especially in women, causes impediments to effective treatment. Education: Education is a one of the most important underlying determinants of health at both individual and community levels. Education reduces poverty through increased employment, and provides skills for attaining better health. Education not only enables women to make informed choices and adopt better health and nutrition practices, it also increases the pool of health care service providers and community educators.
According to the World Bank, “participatory health education for schoolchildren is one of the most timely and effective ways of promoting healthier lifestyles and averting the emerging pandemic of noncommunicable diseases among the next generation of the poor”. Two frequently used education indicators are adult literacy rate and the combined gross enrolment rate. Data for some of the South Asian Countries are provided in the table below: CountryAdult Literacy Rate (%)Combined Gross Enrollment Rate (%) India6160 Bangladesh4153 Nepal4961 Bhutan47
Myanmar9048 Sri Lanka9069 Source: Report of the WHO Regional Consultation on Social Determinants of Health New Delhi, India, 15-16 As the data above clearly shows, there is a direct relationship between these two indicators, with countries having high adult literacy rates also having high CGERS. These indicators are relevant to health since school attendance and literacy affect access to and understanding of health-related knowledge. This in turn affects health-related attitudes and practices, which are very important determinants of health status.
Hence, Bangladesh and Nepal, where the illiterate outnumber the literate are more vulnerable to health problems, than Sri Lanka and Myanmar, where adult literacy matches those of the developed nations. Cultural Factor behind Diseases Widely diffused in each and every society are certain unique cultural norms and practices that create obstacles to attaining and enjoying good health. Prominent among them are: Reliance on ‘quacks’: Large majority of rural households attempt to visit locally available untrained health care providers first.
Commonly known as ‘quacks’, these health care providers rarely have sufficient knowledge to provide treatment to the sick and/or diseased. This leads to a worsened health condition, where trained doctors often cannot provide help, if approached. Child Marriage: Cultural practices in South Asia dictate the marital systems prevailing in the country. Child Marriage is a predominant practice in many South Asian regions, particularly India and Bangladesh, and poses as a major health peril. CountryChild Marriage (%)Birth Before 15 years of age (%) Bangladesh268 India142 Nepal90
Source: Demographic and Health Surveys, http:www. measuredhs. com, StatCompiler In many countries, the arranged marriage of girls at or before puberty is because of culturally influenced mentality such as protection of family honour, increasing the ‘exchange value’ of the girls, etc. Parents may also feel “forced” to marry their daughter early because they fear for her safety and economic security. Child marriage is the major cause worldwide of pregnancies before age 15. Often living in their husband’s household and community, the young married girls face intense pressures to bear children as soon as possible.
This leads to severe health problems because of the following reasons: •The bodies (bone structure, pelvis, and reproductive organs) of the young girls are not yet fully developed; they run a very high risk of complications in pregnancy and childbirth compared with older adolescents. 5 •Prolonged and obstructed labour, which is common among pregnant young adolescents, can lead to haemorrhage, severe infection, and maternal death. 6 •Girls who are married young are also more vulnerable to sexually transmitted infections (STIs), including HIV/AIDS.
This is more common young girls cannot negotiate sexual practices with their partners7 Consumption of culturally specific products such as ‘paan’ and guthka’: These culturally-specific products, consumed particularly in the Indian Subcontinent have two major ingredients, tobacco and betel nut, which have been shown to act synergistically as a carcinogen. In addition, additives, such as gold or silver flakes, contribute to acute toxicity. This consumption is further facilitated by misleading health benefits often purported by manufacturers which included: •Paan and guthka are digestive aids Supari improves memory •Guthka users can perform superhuman feats Environmental Factors behind Diseases Pollution: In South Asia, poorer people burn wood fuel in their homes. This creates Indoor air pollution which contribute to chronic obstructive airway disease, particularly in regions such as Nepal and rural India and Pakistan. Since the South Asian region is developing, increased industrial activities result in higher industrial pollution. This also affects the health of the inhabitants through onslaught of skin and respiratory diseases.
Environmental disruptions: Environmental disruptions occur in the form of natural disasters such as floods, droughts, storms, fires, earthquakes, etc. These play an important role in determining health, since such calamities usually lead to an outbreak of diseases. This is particularly true for Bangladesh where frequent floods and other natural calamities lead to the spread of water-borne diseases such as typhoid, diarrhoea, jaundice, dysentery, etc. Health hazards are further compounded by food shortages and unhygienic living conditions.
This was also exemplified during the Tsunami disaster in 2004. Water quality: Groundwater, especially shallow groundwater, in many sites in South Asia is contaminated with dangerously high levels of arsenic. Long-term exposure to the high levels of arsenic in drinking-water may lead to the following health hazards8: •Reduced rate of child survival •cognitive impairment •cardiovascular diseases •Cancer. In addition to human waste and arsenic, drinking-water in South Asia can also be contaminated with industrial pollutants. The South Asian economies are developing.
This means that a progressively smaller percentage of the workforce is engaged in agriculture, and more of the economy is devoted to industrial production. A common by product of industrial outputs is industrial waste, a melange of chemicals that pose substantial risk to human health. Inadequate Waste Management: The Indian Subcontinent has poor waste management techniques, particularly in the case of monitoring industrial outflows. Industrial wastes have been known to cause ground and river water contamination and tailing pipe leaks which compound the risks associated with such wastes.
Moreover due to natural factors like rain, flooding and wind, tailings have been found to have made their way into people’s homes as well. In India, the problem of waste management extends further into radioactive waste management. Minimal exposure to even low levels of radiation can lead to health hazards like lung cancer. 9 Conclusion The situation is dire, and requires immediate intervention. The following steps can be taken to ensure better health across the South Asian region: Ensuring and Protecting human rights: Health and human rights are closely linked.
Violation or neglect of the human rights of women, men and children can have the most serious health consequences. Such violations can take the form of torture and other forms of violence, denial of food and shelter, etc. Vulnerability to ill-health is reduced by promoting and protecting human rights. It should be noted that access to health care facilities is a basic human right so more health centres should be established in the poorer regions of South Asia. Adjusting Societal and Cultural Norms through awareness building campaigns: Several societal and cultural norms in South Asia are leading to major health hazards.
This includes the practices of gender discrimination and child marriage. To ensure that health hazards arising from these factors are mitigated, these issues should be addressed immediately by the government and other concerned parties. Extensive awareness building campaigns should be launched, and the Ministry of Education in respective countries should take steps to ensure that girls are receiving equal access to primary, secondary and tertiary education. In addition, it should be noted that simply having laws against Child Marriage is not enough to stop this evil practice.
Stringent implementation should be enforced, as and when applicable. Empowering men and women in the rural areas: Providing more economic opportunities to rural inhabitants will have a two-fold advantage. One, it will lead to a fall in the rural urban migration rate, and hence the health problems associated with such migratory patterns will be reduced. Secondly, empowering women will lead to a fall in the health hazards they face due to their vulnerable economic status. Steps should therefore be taken to provide with economic opportunities, which will lead to their self dependence.
Not only will this lead to a fall in the level of prostitution, it will also provide women with the power to have a say in their sexual practices with partners. Formulating stringent policies to ensure environmental: Government should formulate policies to ensure environmental protection. This will ensure that diseases arising due to environmental degradation, particularly air and water pollution, are diminished. Sine waste management is a key issue. Government and other concerned parties should ensure that dumping of industrial waste in the rivers is stopped immediately.
This is particularly true for Bangladesh, where industrial effluent is polluting rivers across the country. References: 1Commission of Social Determinants of Health. Geneva, World Health Organization. Available from: http://www. who. int/social_determinants/en/ 2,Social Determinants of Health, ‘The Solid Facts’, Second Edition, Edited by International Centre for Health and Society Richard Wilkinson and Michael Marmot 3Coalition Against Trafficking in Women, Factbook on Global Sexual Exploitation,Donna M. Hughes, Laura Joy Sporcic, Nadine Z.
Mendelsohn and Vanessa Chirgwin 4San Francisco Chronicle,The Role of Prostitution in South Asia’s Epidemic Push for safe sex in red-light districts, Sabin Russell, Chronicle Medical Writer,Monday, July 5, 2004 5,6,7 International Planned Parenthood Federation, United Nations Population Fund, and Global Coalition on Women and AIDS. 2005. Ending child marriage: a guide for global action. London: IPPF 8INTERNATIONAL CENTRE FOR DIARRHOEAL DISEASE RESEARCH, BANGLADESH J HEALTH POPUL NUTR 2008 Jun; 26(2):123-124 9OneWorld South Asia, Study flags radioactive waste management lapses, Madhusmita Hazarika, 08 December 2008 10MCMICHAEL A.
J. , CAMPBELL-LENDRUM D. H. , CORVALAN C. F. , EBI K. L. , GITHEKO A. , SCHERAGA J. D. , WOODWARD A. , Climate change and human health – risks and responses, WHO 2003, p. 250 11‘Core indicators 2005: health situation in the South-East Asia and Western Pacific Regions’, New Delhi and Manila, WHO Regional Offices for South-East Asia and the Western Pacific, 2005. 12,13,Social Determinants of Health, ‘The Solid Facts’, Second Edition, Edited by International Centre for Health and Society Richard Wilkinson and Michael Marmot