2 Fatima’s story: The coincidence of health deprivation, illiteracy and material deprivation 4

Box 10.2 Fatima’s story: The coincidence of health deprivation, illiteracy and material deprivation 4

Fatima, aged 39, lives with her family in a remote village in the southern part of Punjab, in Pakistan. She and her husband have two daughters and three sons. Her husband Rafiq,

40, is a mason, who earns his livelihood from irregular construction work in nearby villages. Both Fatima and Rafiq never attended school. When they married in 1987, Fatima was only 18. After one year of marriage, she gave birth to a girl, Maria, and one year later, to another one, Razia. As there was no health facility nearby, she did not have access to medical care during and after her pregnancy. Both births were attended by a traditional birth attendant. No vaccines were provided to mother and daughters to protect them from disease.

After one year, Fatima gave birth to another child. However, the baby died on the same day. At that point, Fatima had become weak and anaemic after three close pregnancies. In the absence of education and access to family-planning facilities, she was expecting soon thereafter and gave birth to another child who died on the same day. In the meantime, the two girls were experiencing frequent episodes of illness, sometimes treated by the local hakim (traditional healer). Yet another baby was born. When the newborn fell ill, the family took it to a private clinic at the first sign of illness. The doctor diagnosed that Fatima was suffering from a metabolic disorder – caused mainly by close pregnancies – in which babies have less chances of survival. That baby also died, but Fatima started medical treatment. At the next pregnancy, Jaffer was born: a healthy child,

he eventually survived. The household, though very poor, was happy because one child had survived after three consecutive infant deaths.

In 1998, Maria, then 10 years old, fell seriously ill. Initially, her parents took her to the local hakim. She had developed symptoms of meningitis. As she did not recover, her parents went to the basic health-care unit and were then referred to the district hospital. Maria’s situation continued to worsen. To finance her medical treatment, they sold some assets and borrowed money from their relatives. They took Maria to the tertiary care hospital in the nearby big city, but she died. The household ended up losing their eldest child, selling their small assets, incurring debts and losing income, since Rafiq could not work for an entire month while he was taking care of his daughter.

One birth after the other, life kept on moving, though miserably for Fatima because of physical weakness and her overwhelming sense of grief over the death of her four children. She gave birth to another son and a daughter. One morning, her elder son Jaffer was bitten by a rabid dog on his way to school. Disillusioned by the health facilities around them, they took him to a private clinic. He was given an expensive vaccination that they paid for by borrowing money from their relatives. The treatment proved to be ineffective and the boy began to develop the symptoms of rabies. Following a relative’s advice, they borrowed more money and finally took him to the largest provincial hospital in Lahore. Jaffer died on the bus on the way to Lahore. Once again, Fatima and Rafiq ended up losing

a child, incurring more debts for the treatment and funeral of their son.

They now have two daughters and three sons, all of them apparently anaemic and frequently suffering from illness. None of them is enrolled in school. In the past two years, Rafiq began to lose his eyesight. He visited ‘eye camps’ and hospitals run by various They now have two daughters and three sons, all of them apparently anaemic and frequently suffering from illness. None of them is enrolled in school. In the past two years, Rafiq began to lose his eyesight. He visited ‘eye camps’ and hospitals run by various

This box was written by Arif Naveed and is a true story. 4

The paragraphs above detail how health interacts with other capabilities. There is yet another reason why health deserves a central place in development policy. In other deprivations, individuals who have been deprived in one dimension of their lives might be able to offset their deprivations at some other stage: for example, individuals who were not educated during childhood might benefit from adult literacy programmes, which could train them to be functionally literate. They could also profit from distance learning program- mes. Those who are poor at the age of 25 might still be able to command a decent income later in life, once they have found gainful employment. Similarly, individuals who are unempowered at one point in their lives may become so at a different point through institutional reforms. In other words, it is still possible to reverse these deprivations over a period of time. We are not arguing here that this reversal fully compensates past deprivations. Clearly, an individual who is not deprived in any aspect of her life today but spends ten years of her life with deprivation in terms of income, education and empowerment, has had a lower overall quality of life than others who never faced such deprivations in the first place. But there always remains the possibility of partial compensation for such deprivations.

In contrast, deprivations in health may be irreversible. Once individuals have suffered from incurable diseases, they do not necessarily regain their health over a period of time. Such irreversible health losses may occur at any age. In the case of the elderly, irreversible dementia (the progressive decline in cognitive functions due to damage or disease), neural hearing loss and visual impairment are examples of irreversible health losses. Neural tube defects provide an example of irreversible health losses for children, which are often associated with maternal malnutrition. There are also various congenital disorders and genetic predispositions which cause irreversible health losses. Certain infectious diseases such as HIV/AIDS and congenital syphilis also cause similar losses. There are numerous other diseases that, despite the existence of a cure, remain incurable for the poor because of the fragile health- care systems in much of the developing world. Individuals suffering from such health losses cannot recover from them but can be compensated by other means, given a supportive context and adequate resources and conversion factors. The health and nutritional status of children can potentially determine their achievements in the social, psychological and economic spheres of their

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TOPICS

HEALTH

lives. Given the interactions between health and other capabilities, the incidence of irreversible health loss may indicate irreversible deprivation in multiple capabilities. There is thus an urgent need for appropriate social arrangements to tackle diseases before they occur. Public policy should therefore emphasize the importance of preventive health care, so that individuals are protected from the types of multi-faceted deprivations that could potentially threaten their overall well-being.

Questions

10.1 Take the example of any country where sufficient data are available and determine how adopting different indicators for health could influence policy decisions.

10.2 Trace the effects compromised mental health (or other compromised

health-related capabilities) could have on various dimensions of human development.

10.3 Take a community of your choice and illustrate the various conversion factors that could influence how a given resource (e.g. food) is translated into outputs of value.

10.4 The conventional approach to the problem of undernutrition is the

provision of food. Reconsider how undernutrition would be addressed were it to be framed in the capability approach. Use an example to illustrate your point.

10.5 Health related choices are particularly susceptible to manipulation by market interests. Consider in your own life the factors that influence your choice of the foods you eat, the activities you undertake, and the medicines you seek when ill.

Notes

1 Constitution of the World health Organization, 1946 can be found in the Official Records of the world Health Organization, no 2, p100. 2 The Preamble to the Constitution of the World Health Organization, 1946, can

be found in the Official Records of the world Health Organization, no 2, p100 www.searo.who.int/LinkFiles/About_SEARO_const.pdf accessed January 2009. 3 International anthropometric standards and cut-offs have recently been revised to reflect a more international cohort. However, the debates continue and the applicability of the new standards is still under investigation. 4 Thanks to Shabana Saleem for providing and verifying Fatima’s medical history.