My thoughts: The Business of Poverty - Part 2 of 24

Always, we are in search of "something" and that may be anything - happiness, wealth, health, mating partner, water to drink (or for some alcohol to get intoxicated!!) or else what would be a meaning of our "existence"? Wanting "something", therefore, dictates our livelihood. In contrary: -"not wanting or not knowing what you want" could also direct your life to nowhere or bliss otherwise !!  In this context, the word "existence" itself is a bit heavy in terms of its philosophical  (mind) or even physical (body) derivation. After all, we all know that our existence is a balance between our mind and body if one of these get tilted towards dysfunction, then we starts to suffer. This is a simple truth.

A "Dalit" family in Sankhuwasabha, Nepal @ Anuj Bhattachan

For  part 2 of 24 discourse for the month of January on The Business of Poverty - I would again stress that the word "existence" definitely does have important part to play because it is in our existence that we struggle, we work, we suffer, we cry, we get disease, we get old, we die and of course, it is in this existence too, there can exist disparity in wealth, imbalance in your cognitive skills, or other extremes that you are super rich like Bill Gates (US), Mark Zukerberg (US), Rata Tata (India),  Binod Choudhary (Nepal). All in all - it has been more of wealth as an scale that demarcates us in the metric of rich versus poor in today's material world. It is in this metric that you could be judged (we like it or not !!) - therefore, I like to ponder why there are inequalities, poverty and all other maladies that accompanies with it?? We know there are volumes and volumes of books written to explain why we become poor or to be more specific stuck in the quicksand of "poverty"? There are various explanations through the lens socio - politico - economic observations and understandings as purely the act of "invisible hands" in the realm of market forces or in some corner of academic powerhouses - there could be explanation through the lens of fairness, justice and ethics and even, we could explain the root cause of "being poor" or poverty in terms of behavioral psychology. Whatever may be explanations, one aspect of poverty that we all agree to would be that "in poverty - each human soul suffers !!". When I say "suffering" - it is primarily the health of an individual (which in turns affect the whole family and the  community at large) in terms of physical, mental, social and political well being.

In this discourse – it is always pertinent to start ourselves asking the very basic question: what is “being poor”? What do you understand by poverty? Also, this question can be answered in lay person’s understanding or through academic definitions. First – let us try to understand what it means to be poor in terms of material world? Well – one way would be how you perceive yourself and how other perceives of you or family in terms of wealth that you possess. That means – if your wealth is below what your community agrees as minimum then you are perceived to be poor, otherwise you are not poor. This is one way of perception for “being poor” but I think – this is not complete because many of times we have seen many families in communities who are considered poor in terms of material possession but they seems to be happy despite scarcity. In this case – it is their psychological, familial, philosophical outlook that may play a vital role in portraying yourselves as poor or not poor. Therefore, “being poor” is relative term but not based on an absolute yardstick. When I say this statement, let me give you an example from my observation - we used to wonder why shepherds who lives in highland are always looked happy and jolly though they used to live with bare utilities at their disposal? But now we realize – it is not always lack of material wellbeing that makes you poor but rather it is your mental outlook that may strongly determine whether you poor or not. That is why there is a famous saying that “If you are born in a poor family, it is not your mistake, but it is your mistake, if you die poor!!” This saying says a lot and matches well with a principle in behavioral science, which says human behavior (B) is a function of your personality (P = genetic makeup and habits) and the kind of environment (E) you live in (B = P * E). It is your accumulated bag of habits through learning, influences or education that we behave in a way that is either detrimental to our well-being or guide us for better living [1]. Which means the human behavior is one of the key factors for either “being poor” or “not poor”!!

Our understanding that human behavior is a function of our personality make up and the environment that we live in guides us through the proper channel for further discourse. Here, let us put forward the thesis that “human behavior dictates you being poor or not” This statement initially puts the total responsibility on oneself or control over your destiny, however we have to remember that on further dissection of each variable like personality and the environmental factors then it a bit complex and complicated task to really understand the business of poverty or “being poor”. In this complexity – understanding the personality is itself a huge field that takes us into behavioral science, psychology, psychiatry, genetics, anthropology, sociology, history and even the field of law. While, at the same pace, we have to go deeper into similar field of study to understand the environment we live in and with. After all, our living environment can be both external and internal. Even the internal environment can be further broken down into internal milieu that is the physiology of our body and most importantly - our mind – our control center.

1. Health Behavior and Health Education - Theory, Research and Practice (4th Edition): Karen Glanz, Barbara K. Rimer and K. Viswanath

Seoul, 30 Jan 2016

My thoughts: The New Year 2016 and The Business of Poverty - Part 1 of 24

Every new year bring freshness and hope for better of anything that we wish for - our health, wealth and happiness. It is only through this early beginning in time and space, we strive eagerly to do better with what we envision in upcoming days, weeks, months and years. Well for me - this new year 2016 is a mixture of celebration,  intro-inspection and challenges ahead !! Therefore - I would like to explore oneself, society and the evolving infectious diseases landscape through the lens of socio - political dynamics  in the community, the nations and the globe.

Looking into yourself deeper is a challenge in itself. We got to admit it upfront. For this task, either you  read and write seriously what you see, hear, feel and observe in your "surrounding" environment or seriously consider yourselves as an ascetics or yogi. Well for me - the first path is more realistic and practical, since the second path of ascetics is not wired inside my pysche !! So let us be practical and go into the thinking process now immediately. When we talk of intro inspection or even the act of observing the external world, Rudyard Kipling always comes in my mind the very first. Now and at this moment - I wish I had read and known about Rudyard Kipling - master author early in my early childhood when i was in my village far away from Kathmandu. I also wish, I was brought up in an "academic" environment where I could have read all children books and such books authored by Kipling and O Henry early on during my childhood. Well - not all are fortunate since we did not have even a single library in our district !! But, on the other hand, who else got that infinite liberty to climb up the hills, go fishing, catch frogs, ride buffalo  and taste wild berries and get stunk with wild bees !! Now i think - those days in the wild were our library of nature. It is after all -  it is you and most of the time - the physical and social environment that we grow with is more  environment. With this sensible thought - Kipling  said and wrote famously:

" I keep six honest servants - WHAT, WHEN, WHO, WHERE, WHY and HOW" [1]

Sanitation nightmare in KTM  @Anuj Bhattachan

We can also relate the above statement to "child - like" innocence with curious mind. It is only through curiosity we are able to inquire and raise brave and even funny questions. In ancient Sanskrit texts too - there is an equivalent mantra - कारण: कारण, which means "There are series of reasons for every reason !!" Succinctly - this is exactly the same principle what we strive to excel in the field of applied epidemiology or even in our day to day activities (most of the time we may fail to stick to  divine principle !!). Noteworthy, however, I would say in sincerity - being a student of public health, we have been trained and taught to think through an approach of bio - medical science, where our conceptual framework and knowledge in "real" field scenario seems to be limited !! This is being realized by many public health experts like Paul Farmer along with other prominent researchers, who have seriously felt "real" gap in global health practices in recent 2013 - 2016 Ebola pandemic that created havoc in West Africa [2]. So the question arise among us: "Are we the victim of compartment syndrome?" Here I am not referring to acute surgical condition of muscle inflammation within fascia, instead it is a derogatory term for behavior or thinking pattern that is a bit traditional or confined to narrow thoughts or practice, where our usual prescription would be to "think out of the box". In other word, we could see this pattern more in the field of medicine where there is a race for super specialization so much so that we sometime say that one day there could be "left eye specialist versus right eye specialist" !! This is an increasing trend even in Nepal.

Let us touch a little here and focus ourselves on the subject matter: it is therefore, we can openly debate what it means to be victim of "super - specialization" while forgetting the common problems like cholera / typhoid / HEV outbreaks,  those rampant  in front of our eyes in places / communities with compromised situation in terms of socio - economic - political landscape. Any realistic public health system will definitely prioritize the existing disease burden in the community. On an explanatory note: when I say "compromised" - those who have seen the "real" public health scenario of developing countries do understand well !! So, I will not expand more on this topic here (I will keep the discussion for other posts). All these thoughts and discussion will be the reading and writing tonique for 2016, so I will write more on details in the next posts re: business of poverty related diseases from an angle of "justice as fairness" in terms of fair treatment - health as basic human right. In this 24 part series, I will share more of what I would be able to understand after reading Paul Farmer (especially Infection and Inequalities), Jeffrey D. Sachs (The End of Poverty) and  Amartya Sen (The Idea of Justice and Development as Freedom) in coming posts. After all - it is the truest analysis and understanding of poverty that will help us deal with "real" public health challenges that we face and have to solve in coming years to come [3]. Here, I also urge all those national and international staffs, who perceive and claim to work for the upliftment of people in the developing countries, have to understand poverty and visit those places to understand in real sense "what is suffering as a result of poverty?", otherwise we need to question the very work ethics of developmental works in the name of poverty !! So i would ask you - "have you seen very closely what is poverty? Have you seen children die because the nearest health post is 2 hours walk uphill? Have you dealt with a situation that family does not want to vaccinate their child because they do not know or have an idea what vaccine is and for?" 

In this "thinking" process and boldness to say "I do not have all the answers (in terms of knowledge and money) to solve these poverty re: problems" - I need to visit some of the slums in Kathmandu so I visited all those slums along the Bagmati and Bishnumati rivers. What I see and write here - Kathmandu is a "sanitation nightmare" (above picture). This visit has, therefore, provided me with many ideas to explore in many fronts utilizing science and its tools. Well - for now, let me leave you with these questions (as below) if you have ever  visited in and out of Kathmandu valley or else if you are serious public health researcher, then you should put aside at least 2 days to visit the major slums in the valley:

1. What is poverty?
2. Why people get poor in terms of socio-economic status in the community?
3. What is the population dynamics and its actual understanding in Kathmandu valley?
4. What is the actual pattern and distribution of water borne illness in Kathmandu valley? Can we map it??
5. What are those policy, strategies and action plan from government of Nepal (particularly Kathmandu municipality) to solve huge sanitation challenges in Kathmandu valley?

Reference:

[1] Rudyard Kipling - https://en.wikipedia.org/wiki/Rudyard_Kipling
[2] Bio-social Approaches to the 2013 - 16 Ebola Pandemic -    http://www.hhrjournal.org/2015/12/biosocial-approaches-to-the-2013-2016-ebola-pandemic/
[3] The Neglected Dimension of Global Security - A Framework for Countering Infectious Diseases Crises - http://www.nejm.org/doi/full/10.1056/NEJMsr1600236?query=TOC&

Seoul, 26 Jan 2016