Review Article

Indian J Med Res 126, October 2007, pp 279-288

Social evils, poverty & health

Rajeev Gupta & Praneet Kumar

Department of Medicine, Fortis-Escorts Hospital, Jaipur, India

Received May 29, 2007

There is a close association between social circumstances and health. In India, there is a significant
burden of both communicable and non communicable diseases. Risk factors responsible for these
conditions are underweight, unsafe sex, unsafe water, poor sanitation and hygiene, indoor smoke
pollution, zinc, iron and vitamin A deficiency, tobacco use, high blood pressure, and high cholesterol.
All these risk factors are influenced by social factors and in India the more important factors are
poverty and illiteracy. Changing lifestyles as a result of rising incomes are significant risk factors
for non communicable diseases. The social evils that influence poverty and health are macrolevel
national and regional issues such as physical geography, governance patterns and failures, geopolitics,
economic policy, natural resources decline, population growth, the demographic trap and the fiscal
trap. Household and microlevel factors include the poverty trap, cultural barriers, lack of innovation
and saving, absence of trade or business, unemployment, technological reversal, adverse productivity
shock, social issues related to females, and adolescent social issues. Social determinants important
for non communicable diseases, defined by the World Health Organization include the social gradient,
stress, early life events, social exclusion, improper work conditions, unemployment, lack of social
support, addiction, food scarcity or excess and uneven distribution, lack of proper transport, and
illiteracy or low educational status. There are multiple pathways through which social factors
influence health, and pathophysiological mechanisms involve homeostatic and allostatic changes in
response to stress, neuroendocrine changes and altered autonomic functions, and abnormal
inflammatory and immune responses. A concerted action to eradicate these social evils shall have to
focus on reducing poverty, improving educational status and providing equitable and accessible
healthcare to all.

Key words Cultural barriers - health inequity - health risk - national issues - poverty - social evils

Poverty is one of the most important social evils
and a major determinant of ill health 1. From time
immemorial it is known that poor social status is a major
determinant of disease and reduces longevity. The
Charaka Samhita recognized that community structure
and functioning was an important cause of disease in
an individual. The association of individual illness
causing community disturbances and poverty and vice
versa was noted2. Health status is strongly determined
by socio-economic position and a large body of literature
from developed countries demonstrates that most causes
of deaths occur at greater rate in groups with lower
socio-economic status3. In this article we enumerate
social circumstances and evils leading to poverty that

279
280 INDIAN J MED RES, OCTOBER 2007

Table I. Estimates of ten leading causes of deaths in Global Burden of Diseases Study
Developed countries Developing countries
Rank Cause % of total deaths Rank Cause % of total deaths
1 Ischaemic heart disease 22.6 1 Ischaemic heart disease 9.1
2 Cerebrovascular disease 13.7 2 Cerebrovascular disease 8.0
3 Trachea, bronchus, lung cancers 4.5 3 Lower respiratory infections 7.7
4 Lower respiratory infections 3.7 4 HIV/AIDS 6.9
5 COPD 3.1 5 Perinatal conditions 5.6
6 Colon and rectum cancers 2.6 6 COPD 5.0
7 Stomach cancer 1.9 7 Diarrhoeal diseases 4.9
8 Self-inflicted injuries 1.9 8 Tuberculosis 3.7
9 Diabetes 1.7 9 Malaria 2.6
10 Breast cancer 1.6 10 Road traffic accidents 2.5
COPD, chronic obstructive polmonary disease
Source: Ref. 4

is a major social evil. Mechanistic pathways from Table II. Disease burden estimates in India (National Commission
adverse social circumstances to ill health are then on Macroeconomics and Health, 2005)
discussed and some suggestions are made for Disease condition Estimate of cases
ameliorating the social evils. (thousands)

Health issues in India and developing countries Diarrhoeal diseases per year 76000
Mental health 65000
The Global Burden of Diseases Study reported COPD and asthma 40500
major causes of mortality, disease burden and risk Diabetes 31000
factors thereof in various parts of the world4. The top Cardiovascular diseases 29000
Blindness 14100
ten leading causes of mortality in developed and Tuberculosis 8500
developing countries are shown in Table I. HIV/AIDS 5100
Cardiovascular diseases (ischaemic heart disease and Malaria and vector borne diseases 2037
cerebrovascular disease) are leading causes in all Injuries 980
regions of the world. In developing countries, Cancer 807
infections of respiratory tract, HIV/AIDS, diarrhoea, Source: Ref. 9
tuberculosis and malaria have emerged as important
causes. In India, leading major cause-groups of deaths
Ten leading causes of disability as assessed by
during 1984 to 1998 have been reported by the
disability adjusted life years (DALYs) has also been
Registrar- General of India5. Trends show that there
reported by the WHO8. Globally the important causes
has been a significant decline of proportionate
were lower respiratory infections, perinatal conditions,
mortality from infectious diseases from 22 to 16 per
HIV/AIDS, unipolar depression, diarrhoeas, ischaemic
cent whereas mortality from cardiovascular diseases
heart disease, cerebrovascular disease, road traffic
has increased from 21 to 25 per cent and due to injuries
accidents, malaria and tuberculosis. Indian National
from 8 to 12 per cent (P<0.05)5. The reliability of
Commission on Macroeconomics and Health 9 has
mortality data has been questioned in terms of medical
reported that communicable diseases, maternal and
classification of deaths as a large number of deaths
perinatal conditions as well as non communicable
are recorded as senility or old age and a major cause
diseases are major causes of disease burden (Table II).
of this group is cardiovascular disease, hence the
current sources may underestimate the deaths due to The Second Global Burden of Diseases Study4
cardiovascular diseases. The ongoing prospective quantified more than 20 health risk factors that influence
Sample Registration System Verbal Autopsy (SRS-VA) health of populations. Major risk factors identified were
Million Deaths Study in India6 and the Prospective (i) childhood and maternal undernutrition leading to
Urban Rural Epidemiology (PURE) Study7 would be childhood and maternal underweight, iron deficiency
able to provide more definitive answers regarding anaemia, vitamin A deficiency and zinc deficiency; (ii)
causes of deaths and their risk factors in India. adult nutritional factors related to high blood pressure,
 GUPTA & KUMAR: SOCIAL EVILS, POVERTY & HEALTH 281

high cholesterol, and obesity; low fruit and vegetable
intake, and physical inactivity; (iii) addictive substances
use such as smoking and oral tobacco use, alcohol use,
and illicit drug use; (iv) issues in sexual and reproductive
health and unsafe sex and ineffective contraception; (v)
environmental and occupational risk factors such as
unsafe water, sanitation and hygiene, urban air pollution,
indoor air pollution from household use of solid fuels,
lead exposure, global climate change and selected
occupational risk factors; and (vi) other selected risk
factors such as contaminated injections in healthcare
settings and child sexual abuse. There was a difference
in risk factors causing disease burden or mortality. The
top ten risk factors for mortality as well as increased
burden of disease are shown in Table III10. Social
circumstances and poverty are the major determinants
of all these factors.
Social evils
A social problem is defined as a situation
confronting a group or a section of society which inflicts
injurious consequences that can be handled only
collectively11. There are a number of social problems
in India 11. These have been identified as poverty,
illiteracy, unemployment, population explosion,
communalism, secularism, and regionalization, youth
unrest and agitation, child abuse and child labour,
violence against women, urbanization, crime and
criminals, juvenile delinquency, alcoholism, drug abuse
and drug dependence, HIV-AIDS, terrorism, corruption,
bonded labour, black money and more recently
overweight/obesity in the urban subjects coupled with
changing lifestyles.
Multiple efforts to accurately identify social
determinants of health have been performed and some
efforts have evolved recently. Social determinants of
health were enumerated by Marmot and others at the
Solid Facts Program of the World Health Organization
(WHO)12. The factors identified were social organization,
early life events, life-course social gradient, high-
unemployment rates, psychosocial work environment,
transport, social support and cohesion, food, poverty and
social exclusion, and individual health behaviours. All

Table III. Top ten risk factors for increased mortality and burden of disease
Causes of increased burden of disease
Causes in different economic regions
Rank Major causes of Global causes High mortality Low mortality Developed regions
mortality developing regions, developing regions
such as India
1 High blood pressure Childhood and maternal Underweight Alcohol Tobacco
Underweight
2 Smoking and oral Unsafe sex Unsafe sex High blood pressure High blood pressure
tobacco use
3 High cholesterol High blood pressure Unsafe water, Tobacco Alcohol
sanitation and hygiene
4 Childhood and maternal Smoking and tobacco Indoor smoke from Underweight High cholesterol
underweight use solid fuels
5 Unsafe sex Alcohol use Zinc deficiency High BMI High BMI
6 Low fruit and vegetable Unsafe water, sanitation Iron deficiency High cholesterol Low fruit and vegetable
consumption and hygiene intake
7 Overweight and obesity High cholesterol Vitamin A deficiency Low fruit and Physical inactivity
vegetable intake
8 Physical inactivity Indoor air pollution High blood pressure Indoor smoke from Illicit drugs
solid fuels
9 Alcohol use Iron deficiency anaemia Tobacco Iron deficiency Unsafe sex
10 Unsafe water, sanitation Overweight and obesity High cholesterol Unsafe water, Iron deficiency
and hygiene sanitation and
hygiene
BMI, body mass index
Source: Ref. 4
282 INDIAN J MED RES, OCTOBER 2007
these factors are classified as social evils that directly
influence health. Because non-communicable diseases
are major health issues in Europe and developed countries
these factors, though important in the Indian context,
reveal only half the story. For example, illiteracy and
low educational status is a major disease risk factor but
not part of the WHO agenda as this is not a serious
problem in Europe3. A major development to address
various social issues and poverty was the landmark
United Nations Millennium Declaration in the year 2000
by various Heads of States and governments. The
declaration articulated Millennium Development Goals
(MDGs) 13 which include specific targets for social
engineering to bring about equitable prosperity and
health. The specific targets include poverty reduction,
increasing primary education, promoting gender equality,
reducing childhood mortality, improving maternal health,
combating infections such as tuberculosis, HIV/AIDS
and malaria, ensuring environmental sustainability, and
development of a global partnership for development.
There are specific targets in areas of poverty reduction,
provision of education to all children, reducing the
percentage of people without access to water and
sanitation, reduction in infant, childhood and maternal
mortality, control in spread of diseases such as HIV/AIDS
and malaria and improving the lives of slum dwellers.
Social evils: National and regional issues
The social evils can be viewed at a macrolevel that
include national and regional issues. They can also be
assessed at a microlevel of the household and an
Table IV. Major social determinants of poverty and ill-health
National/Regional level factors:
(i) Physical geography
(ii) Governance patterns and failures
(iii) Geopolitics
(iv) Economic policy
(v) Natural resources decline
(vi) Population growth
(vii) The demographic trap
(viii) The fiscal trap
Household and local level factors:
(i) Poverty trap
(ii) Cultural barriers
(iii) Lack of innovation and saving
(iv) Absence of trade or business
(v) Unemployment
(vi) Technological reversal
(vii) Adverse productivity shock
(viii) Gender issues
(ix) Adolescent health issues
Source: Ref. 13
individual. The noted economist, Jeffrey Sachs, has
provided listing of social determinants of poverty13.
These determinants can also be considered evils that
lead to poverty and their importance as determinants in
health related outcomes can be evaluated (Table IV).
Multiple international and national level factors are
important determinants of poverty and ill health.
Extreme poverty which has been defined by the World
Bank as income of less than $1 per day per person ($1.08
at 1993 prices and $1.53 at current prices) is a problem
of developing countries such as India. In year 2004,
986 million persons (18% of total world population)
lived at this level. This is a sharp decline from 1.25
billion (29% of the world population) in 1990 14 .
Developmental economists speculate multiple reasons
for this decline including changes in international,
national, local governmental and municipal policies13.
A better understanding of reasons of poverty and
amelioration of some of them has also led to this
situation. There are international and national factors
amenable to significant improvement and include the
following:
Physical geography: Nations are a geographic entity
and location-based geographical advantages and
disadvantages play an important role in societal and
economic development. Geographic location is also an
important determinant of health. For more than two
thousand years it has been known that bad air causes
multiple diseases including infections and
deficiencies15. Although scientifically erroneous (this
hypothesis was explanation of malaria and cholera
epidemics), there is merit in considering these infections
a result of bad location. Other infections that are known
to be due to geographic disadvantage are yellow fever,
African trypanosomiasis and many vector borne
diseases10. Nutritional deficiency syndromes in Sub-
Saharan Africa are also a result of adverse locational
circumstances13. Non communicable diseases such as
chronic respiratory disease and asthma in specific
locations of the world and especially high rates of
asthma in developed countries can also be explained
by geographical factors16. Higher physical activity levels
and low rate of obesity in rural locations in developing
countries explain the rural-urban differences in coronary
heart disease 17 . Physical geography should be
recognized as an important determinant of poverty and
identification of unique strong points can be an
important harbinger of social and economic change
leading to reduced ill health. Other geographic factors
related to health include transport conditions of the
 GUPTA & KUMAR: SOCIAL EVILS, POVERTY & HEALTH
country and proximity to seaports and roads, costs of
transportation, and population density in various
locations and availability of health care locally.
Agronomic conditions are related to physical
environment and influence crop choice, nutrition and
income levels. Patterns of soil, topography, hydrology
and land use also determine nutritional deficiency and
infections. Ecosystem and climate variability such as
El-Nino fluctuations and global warming are
international geographical issues that have direct
bearing on climate, monsoon, poverty and health.
Governance failure: The effect of political environment
on population health has not been adequately
researched. It is maintained that democracy may have
an impact on health independent of the effects of socio-
economic factors 18 . Democracy may also affect
population health indirectly by affecting socio-
economic position. To investigate these theoretical links
Safei has measured indices of population health (e.g.,
mortality rates and life expectancies) across a spectrum
of countries categorized as autocratic, incoherent, and
democratic polities19. The regression findings support
the positive influence of democracy on population
health. Incoherent polities, however, do not seem to have
any significant health advantage over autocratic polities
as the reference category. Governance patterns and
failures is a poorly understood area of social research.
Medical benefits of democratic system are well
recognized although democracy is not a pre-requisite
to good health20. More important issues are civil and
political rights especially in terms of increasing
education, universal health access and affordability.
Public health management systems are important in this
regard and in India there are non-existent preventive
and promotive health support systems in rural and
especially urban locations9. Decentralization and fiscal
federalism, corruption pattern and intensity, political
succession and longevity, internal violence and security,
and ethnic, religious and cultural divisions of the nation
are all important aspects of governance and
determinants of poverty and health13,19-21. Unfortunately
in most of the developing world these are realities and
have led to considerable ill health and disease burden1,3.
Geopolitics: The country’s security and economic
relations with rest of the world have an important
bearing on poverty and health. Critical cross-border
security threats such as in Kashmir have led to multiple
health problems in that State. A very high prevalence
of coronary heart disease in rural locations that is similar
to urban subjects has been reported from Kashmir22.
283
Refugee movements, terrorism and cross border warfare
all have bearing on health. Trade barriers also impede
economic development and sustain poverty, illiteracy
and ill health.
Economic policy:Economic policy within a country
such as business environment, trade policy, investment
policy, infrastructure and human capital all are major
determinants of poverty. Absence of proper long-term
economic policy can lead to financial disaster and can
have adverse health consequences. Failure of Russian
communism to sustain economic growth of the
population led to dismantling of the Russian federation
and led to a sudden increase in middle age mortality23.
Increased cardiovascular mortality in early and mid
1990s in Russia was a direct influence of the failed
economic policies24.
Natural resource decline: Bolivia in South America
faced a major economic crisis following drying up of
tin mining and decline in coca production. This situation
led to a massive inflation and poverty trap which was
later remedied by fiscal means13. Increased health
related outcomes during the years of depression are well
known25. Decline in natural resources such as rain and
ground water in many parts of India led to droughts in
central and south India. This was associated with an
epidemic of farmer suicides26.
Population growth and demographic trap: One of the
major pathways between society and ill health is through
the demographic trap. The societal health trends such
as birth rates, death rates and migration rates all
influence the population and demographic conditions
of the household. Increasing population and adverse
social and demographic conditions lead to individual
poverty and fiscal trap13,27. Associated individual and
group cultural barriers can play an important role in
producing and sustaining poverty and ill health.
Undernutrition related diseases and infections are
important consequences.
Household and individual level factors
There are multiple local factors which are important
and include many factors that hinder economic
development and perpetuate individual poverty.
Poverty trap: Household surveys in countries reveal
the proportion of households living in extreme poverty.
Extent of extreme poverty can also be judged by
estimation of proportions of households lacking access
to basic needs in schooling, health care, water and
sanitation, electricity, roads and nutrition. Spacial
284 INDIAN J MED RES, OCTOBER 2007
distribution of poverty can also be estimated. These
parameters provide important data on prevalence of
social evils in a country at the household level. It is
well known that poverty begets poverty and lack of basic
amenities such as education and preventive healthcare
are important mediators. The Indian National Family
Health Surveys (NFHS) report on economic parameters
as well as health status of the country. The surveys were
carried out in 1992-93 (NFHS-1) 1998-99 (NFHS-2)
and 2005-06 (NFHS-3)28. There has been an increase
in economic prosperity as judged by household
ownership of motorized vehicle or television and there
has been a significant increase in availability of pucca
housing, electricity, piped drinking water and toilet
facility in the country as a whole as well in rural and
urban locations. Increase in education correlates well
with increasing vaccination coverage and improving
childhood nutrition with declining infant mortality1.
Study of women’s health issues also reveal an increasing
contraceptive use, availing of any antenatal care and
rise in institutional deliveries in India. The decline in
measures of poverty related illnesses suggest that India
may be coming out of the poverty trap.
Cultural barriers: There are multiple cultural barriers
and social evils operative at household and individual
level which influences health. These relate to class,
caste, ethnicity, religion and gender inequality. Gender
issues are especially important and in India women and
girls face severe discrimination in personal rights (e.g.
in sexual and reproductive choices) and access to
personal services such as education, health facilities and
family planning services. Corruption in public life is a
major issue and is a way of life in India and many
developing countries perpetuating poverty21,27. Studies
have shown that Sub-Saharan African countries (Ghana,
Senegal, Mali and Malawi) where corruption perception
rank is high, indicating rampant corruption, have lower
per capita economic growth as compared to developing
countries with comparable corruption and income13.
Nuclear family: Disappearance of the traditional joint
family system in India has led to a variety of health
issues that range from increasing psychiatric and
psychosocial diseases such as depression and suicides
to anxiety related syndromes4. The recent phenomenon
of increasing childhood obesity in various developing
countries including India among the poor and middle
socio-economic groups is a result of societal change of
shifting from joint families to nuclear families with
increasing disposable incomes and sedentary
lifestyles29. Increasing non communicable diseases
(cardiovascular disease, diabetes) in India can be partly
explained by this change.
Lack of innovation and saving: Life is a dynamic process
and in the current world economic scenario there has
to be a constant innovation to achieve income. Use of
innovative approaches whether in agricultural
production (Indian green revolution) or high-end
technology (Indian infotech boom), are required for
sustained economic growth of a nation or an individual.
Health problems are not only the result of poverty but
ill health itself can contribute to lack of savings. A study
reported that in India more than 11 per cent subjects
are pushed below the poverty line by household
expenditure on health30.
Absence of trade or business and unemployment: Trade
can be affected by local factors, and lack of trade or
means for livelihood is a major factor perpetuating
poverty in rural locations. It can also be hampered or
blocked altogether by social evils such as violence,
monetary chaos, price controls and other forms of
government interventions that may impede
specialization and trade. Unemployment and
underemployment are a major risk factor for poverty1
and can lead to a variety of non communicable diseases
such as depression, neuropsychiatric diseases,
addictions, and cardiovascular diseases13.
Technological reversal and adverse productivity shock:
When due to ill health the family size shrinks as is
happening in Sub Saharan Africa there is loss of
knowledge of traditional means of livelihood. This
microlevel technological reversal can be an important
cause and effect of ill health. At a macrolevel, failure
to adapt to evolving technologies as is happening in
many poor households, can have long lasting adverse
impact on health. Similarly, an adverse event at a local
level can wipe out gains from farming or similar menial
occupations and cause poverty and sustain
undernutrition related illnesses.
Gender issues: One of the most important social evil
that perpetuates ill health in a society is gender bias or
female under-empowerment. These issues have been
discussed11. In India this occurs at multiple levels from
womb to tomb malpractices such as (i) female foeticide
as is widely practiced in north Indian States31; (ii)
selective undernutrition of the girl child and healthcare-
related discrimination leading to greater female child
mortality; (iii) lack of proper education to the girl child;
(iv) child marriage, especially early girl-child marriage;
(v) multiple pregnancies and lack of maternal healthcare
 GUPTA & KUMAR: SOCIAL EVILS, POVERTY & HEALTH 285

services, a high mortality is observed in most poor

Indian states32; (vi) household violence; (vii) divorcee
and widow discrimination; and (viii) lack of old age
security; etc. Multiple agencies such as National Sample
Survey Organization, Central and State Ministries of
Health and Family Welfare, Ministries of Women and
Child Development, and National Family Health
Surveys have focused on these issues but these continue
to remain as major social evils in the country4.
Adolescent health issues: Another major issue in India
and many other developing countries is lack of proper
direction to the adolescents with regards to lifestyle
disease prevention. This is resulting in a burgeoning Fig. 1. Under 5 mortality rates per 1000 live-births by socio-
economic quintiles in India and some developing countries.
epidemic of obesity in Indian metropolises and big
cities33. Lack of gender sensitive education is also Source: Adapted from Ref. 38
leading to new infections such as HIV/AIDS and other death1. Childhood mortality is a good example and under
sexually transmitted diseases34. Another important 5 mortality varies from 316/1000 live births in Sierra
contributor to disorders of reproductive tract and Leone to 3/1000 in Iceland, 4/1000 in Finland and 5/
sexually transmitted diseases is indulgence and 1000 in Japan37. Under 5 mortality rates for India,
experimentation by the urban youth. These are major Indonesia, Brazil and Kenya (Fig. 1) show a clear
social problems and improving the overall educational gradient with lowest mortality in the richest fifth as
status and focused learning is the way ahead. compared to the poorest fifth38. Similar differences are
Social determinants of health inequity observed in adult mortality rates, especially premature
mortality. Poverty in the form of material deprivation
The gross health inequalities that are observed
is an important determinant. However, the root causes
within a country and between countries are a major
lie deeper and Marmot35 has elegantly summarized these
challenge for healthcare35. For example, within India
causes of causes for communicable and non
there are substantial variations in overall mortality rates
communicable diseases. It is well known that dirty
as well as diseases specific mortality rates in different
water, lack of calories and poor nutrition, poor antenatal
States; infant mortality rates are also widely
care and lack of quality medical care are major
disproportionate 36. A large body of evidence now
determinants of communicable diseases. The major
recognizes that social evils are at root of these health
causes of deaths in all continents of the world, except
inequalities.
Sub-Saharan Africa, are now non communicable
Poor and vulnerable people such as the children conditions and the risk factors are different. The Global
and the elderly are much more prone to illness and Burden of Diseases Studies4 have identified that risk

Table V. Social determinants of health: Focus on noncommunicable diseases

Social determinants Examples
The social gradient Socio-economic class differences based on various indices with greater mortality in low social groups
Illiteracy Low educational status and its correlation with various communicable and non-communicable diseases
Stress Importance of actual or perceived stress in causation of disease
Early life events Foetal malnutrition and programming as determinant of adult diabetes, respiratory and cardiovascular diseases
Social exclusion Employment and home related exclusion. Non-participation in social activities
Work Work stress and gainful employment
Unemployment Risk of unemployment
Social support Lack of home-based and local support systems
Addiction Tobacco and other major addictions
Food Improper food choices with more saturated fats and less fruits and vegetables available to the poor
Transport Lack of spaces for physical activity and pollution.
Source: Ref. 12, 42
286 INDIAN J MED RES, OCTOBER 2007
factors for these conditions are being overweight,
smoking, alcohol and poor diet (Table III). The WHO
Solid Facts program 12 has enumerated 10 social
determinants (evils) as root causes of these conditions.
Authors have added illiteracy which is also a major
determinant (Table V).
It is important to realize the importance of these
social factors because poverty is not the only cause of
ill health or shortened lifespan35. There are countries
whose gross national product (GNP) is high that have
similar lifespan to those with lower GNP. For example,
USA with GNP of $34,000 has life expectancy of 76.9
yr while countries with a substantially less GNP
(< $10,000) such as Costa Rica and Cuba also have an
average life expectancy of 77.9 and 76.5 yr. In India,
Kerala, despite having a low income, has infant
mortality rates much better than the US and many more
developed countries implying importance of other
factors39. Whether these factors work through the social
gradient or relative material deprivation has engrossed
many philosophers. Amartya Sen 40 focuses on
increasing capabilities to achieve human needs in
societies suffering from absolute material deprivation
while Robert Fogel 41 calls for increasing spiritual
resources in societies with relative rather than absolute
deprivation. We believe that increasing literacy levels
and knowledge-based empowerment of the population
are important means to reduce health inequalities42.
Pathophysiological mechanisms
Social factors work through biology to cause
diseases43. A major issue for socio-economic factors in
acute and chronic disease causation relates to whether
these factors are direct causes leading to biological
changes or influence the pathophysiological pathways
by inducing changes in health behaviours43.
It is widely known that social disadvantages lead
to abnormal health related behaviours such as increased
smoking and poor diet. There is a large body of literature
showing that low socio-economic status is associated
with smoking which is a major disease risk factor42.
Other disease risk factors (Table III) are also aggravated
by social evils. For India, and other high mortality
developing regions, factors such as underweight, unsafe
sex, unsafe water, sanitation and hygiene, indoor
pollution, deficiency of zinc, iron and vitamin A are all
influenced by poverty and its determinants (Fig. 2).
Direct biological effects of social factors on chronic
disease causation are through stress related abnormal
homeostatic and allostatic mechanisms. The
Fig. 2. Inter-relationship of social evils and health risks.
neuroendocrine responses appear to be mediated via
sympathoadrenal and hypothalamic-pituitary-adrenal
systems. The concept of allostasis is the ability to
achieve physiological stability through change and the
allostatic load hypothesis links the psychosocial
environment to physical disease via neuroendocrine
mechanisms43. The allostatic load, potentially leading
to damage induced by stress, is considered relevant in
cardiovascular disease, cancer, infections, and cognitive
decline, and has been described as a sign of accelerated
ageing. The price of adaptation to external and internal
stress is wear and tear of the organism. The main
mechanisms of disease thus include (i) homeostatic and
allostatic changes in response to stress;
(ii) neuroendocrine changes and alternation in
autonomic functioning; (iii) abnormal inflammatory and
immune responses; and (iv) disturbances of coagulation,
insulin and lipid metabolism. Further research on the
inter- relationship of psychosocial, hormonal, metabolic,
and disease processes is valuable for advancing
scientific understanding and developing a proper public
health policy.
Conclusions
Jeffrey Sachs, the noted developmental economist,
has suggested a clinical economics based approach to
tackle social ills and poverty13. A concerted action is
required by the rich countries as well as the poor. The
poor countries must take poverty ending and healthcare
promoting approaches seriously and devote more share
to these issues rather than to war, corruption and
political infighting. Millennium development goals have
been evolved to fight poverty and ill health. It is hoped
 GUPTA & KUMAR: SOCIAL EVILS, POVERTY & HEALTH 287

Table VI. Importance of water supply in every house

Service level Distance/time Likely volume of Health risk Intervention priority
water collected and action
No access More than 1 km, over 30 min Very low, 5 litres per Very high Very high
roundtrip capita/day
Basic access Less than 1 km and 30 min About 20 litres per capita/day High High
Intermediate At least one tap in premises or About 50 litres per capita/day Low Low
access close by
Optimal access Water supply within house with 100-200 litres per capita/day Very low Very low
more than one tap
Source: Ref. 45

that targets are met by the year 2025, if not earlier. The
Indian President as well as Prime Minister share this
vision 44 and have implemented these via multiple
agencies that are at work nationally and regionally.
Inspite of the internecine problems India has achieved
much for achieving reduction in social evils and
poverty21 and it is expected that sociological change
can further advance the goal of health for all. For
example, fulfillment of MDGs relating to water and
sanitation has a strong link to strengthening overall
sociological perspective and improving health 45
(Table VI).
More appropriate data are needed to evaluate social
evils, poverty and health care systems. Good practices
require that policies are evolved according to sound
statistics46. Transition from data to policy needs (i)
reconciliation of data from several sources; (ii) fostering
communication and transparency, including reaching
out to media for dissemination; (iii) promoting country
ownership of data and statistical analyses; and (iv)
addressing conflicts of interest, including those arising
when workers responsible for attainment of health goals
are also charged with measurement and monitoring of
progress47. A target driven approach is required and has
been recommended48.
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