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  • Writer's pictureannaschurmann

Does public health practice punish the poor?

“The quasi-religious belief in the power of the individual to overcome their own problems, embedded deeply in Anglo-American culture, and within much of psychotherapy itself, has long been used by the powerful as a justification for disciplining the poor.”

Zoe Williams, in today’s Guardian. You can read the full article here.

I was trained in health behavior, a discipline that seeks to promote changes towards optimal health behaviours (such as giving birth in a facility, getting your children vaccinated, or exclusive breastfeeding).

A worrying trend in this field is that we are constantly examining the behaviours and lifestyles of the poor. We subject them to surveys, qualitative interviews and community mapping. We encourage them to eat vegetables, wear condoms, wash their hands, exclusively breastfeed, exercise….it can seem like harassment.

However, the poor generally don’t have that much agency to shape their own lives. Much of their existence is shaped by structural factors; decisions made in company boardrooms, or at the Planning Commission (in India), or on the Hill (in the US).

For example;

A woman and her family abandon their family plot after it is desiccated by drought, and come and live in an urban slum. She cannot breastfeed her youngest for the six months required because she has to work 12 hour-days as a maid. She gets up a 5 am every day to queue for water, but doesn’t have time to boil it for 20 minutes to make it potable, as she has to leave for work. Much of her salary goes on her bus pass. The slum doesn’t have latrines, so they defecate in the alley behind their hut. Despite being on the pill, she finds out she is pregnant again, and knowing she cannot afford another child, she goes to the quack in a neighbouring slum because he can assure privacy where the public facility cannot, and he will accept delayed payment.

How much more can this woman actually do? Of course, to the extent there are things she can do, we need to highlight them and make them easier. We should not assume she, or anyone is completely disempowered, even for a second. All people can do amazing things. But it can seem cruel to focus our attention only on her, when the elites – who can do so much more - are let off the hook. It's simply not effective problem solving to only look at the behaviour of the poor for solutions.

I have often thought that the tables should be turned, and instead we should examine the decision-making processes of the rich and powerful – including activists, lobbyists and other elites who shape policy and practice. Why do they fail to provide a living wage? Why do they keep buying cars? Why do they restrict access to safe abortion? Why don’t they provide clean potable water to all? Why do they engage in unsustainable industrial practices that divert water from where it’s needed the most? Why do they keep buying bottled water? Why do educated “feminist” activists restrict contraceptive choices to poor women? Why do activists prevent piped water to slum communities? Why aren’t young women being vaccinated against HPV right now?

These are actually fascinating research questions, but the challenges in doing this kind of research are almost amusing. No-one would fund it. Can you imagine reading out the consent form? Imagining this scenario makes you realize that research is a form of social discipline, one that most members of the elite would not abide…(they are tracking all our online behavior anyway, so maybe consent forms are no longer required!).

I can recommend two excellent refreshing books where elite perceptions are examined:

  • Naomi Hossain’s Elite Perceptions of Poverty in Bangladesh (the research was actually funded by DFID), and

  • Rana Dasgupta’s Capital (this book has literary pretensions, and it not explicitly a book about elite decision making).

I would love to hear other examples of where this is done, so please let me know if you have any leads.

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