“The biggest enemy of health in the developing world is poverty.” (Kofi Anan) That’s only partly correct, because many studies over many years have demonstrated that even in the developed world the offering of healthcare and the effective access of healthcare depends on the socioeconomic status of the patient. The latest example is an article In the New England Journal of Medicine about health disparities amongst 11-year-olds in the US. And here we don’t speak about poverty but social marginalization.

“Approximately 1.2 billion people in the world live in extreme poverty. Poverty creates ill-health because it forces people to live in environments that make them sick, without decent shelter, clean water or adequate sanitation.” (WHO) This is also the reality in Nicaragua, where I had the opportunity to work in the mountains for six weeks.

In a breathtaking landscape people have no access to clean water, and a quarter of the dwellings are in such bad conditions that they are considered to be inappropriate housing for humans. 95% of them are poor or extremely poor, accessing health in the towns is difficult and at least for the medication one has to pay.

Those people live off the income of the coffee harvest for six months and off their own corn and bean harvests of their mountainous terrains for another six months. During that time there is not a single cent in the house. If you run out of money too early, you starve or eat corn bread only until the harvest is ready for collecting. Rice at the price of 63 cent/kg is often unaffordable.

Those are the social markers for the situation people find themselves in. Often they don’t know what they needs, because ill health is seen as the rule: children are born with normal weight and from the time they need more than breast milk they nearly unanimously fail to gain sufficient weight – a sure sign of malnutrition.

Their coughs and colds and diarrhoeas thus are more likely to kill. Infectious diseases are frightfully common; often more than 10 people live in the small huts, which simultaneously serve as storage rooms. Adults complain more about work related health problems – aches and pains, skin problems and chronic indigestion. I guess that 100% of the stomachs are infected with Helicobacter, antibiotic therapy however is far too expensive, apart from the fact that they probably would re-infect themselves immediately in those crowded conditions.

Thus only the easing of their nagging pains and niggling stomachs is possible and people are grateful for that. This is tropical medicine – the medicine of poverty. Even the true tropical diseases are diseases of the poor, because they can’t afford preventive measures. Malaria fortunately has been eradicated, although it can be imported again from surrounding areas. Dengue fever has become rare due to government efforts, but Chagas, which causes heart failure, is still common. Those blood sucking bugs just love to hide in the walls of the decrepit buildings, although a renovation would easily get rid of them.

Reading about the WHO, I also came across it’s definition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” and I guess doctors also will remain busy this side of the ocean.

Donations for Doctors for the 3rd World:

Account 488 888 0, Sorting code 520 604 10, EKK Bank, Germany. IBAN: DE12 5206 0410 0004 8888 80, BIC: GENODEF1EK1, code word Spain, or in our surgery.