In my Somaliland work, our main question was to ask where are the children who need surgical care in the country and did they get that care. We found that 75% of them did not get to a hospital because of two main reasons: Geography, they lived too far away. (Here’s the fun geospatial analyses we did! Below is a map of Somaliland with the 6 regions divided by the dark lines. The “H” are the hospitals in the country and the dark green or red parts are the areas where children live more than 4 hours away from a hospital. It’s a lot of children in the country!).
The other reason was poverty, they couldn’t afford it. And our data showed that the main predictor of going into poverty and never coming back out was having a child with a surgical need, regardless of that family’s income or household size.
We call this descent into poverty a poverty trap. Below you see a u-shaped curve. Some families will have one acute health event (like a trip to the ER or a trauma) and that plunges the family into poverty (that’s below the dotted line titled ‘Poverty Threshold’). Some families can climb out of poverty after the health event because of savings or borrowing money. Other families, though, get stuck in poverty and never get out. That’s why our data was so important! I thought that the reason families got stuck in poverty in Somaliland would be because of their baseline income levels or household size (it’s expensive anywhere when you have a lot of children to feed). We found that it was having a child with a surgical need that plunged families into poverty - regardless of household size or income!
Families will do what it takes to get to care, including going into poverty. Many of these families have to make decisions of seeking care for one child or feeding the others.
The next question is what do we do about it? How do protect them from poverty?
The first thing we did was model what it would look like if we offset all healthcare expenses for these families. Would that protect them? I thought it would. What the data shows is that it protects some, but only the richest families in the country. For the poorest of the poor, it didn’t protect at all. (Also, for you nerdy-types like me, the linked article goes into detail on how we calculated all of this. Viva la’ formulas!)
In the figure below, we stratified the families with children with surgical needs into income levels, from richest to poorest. Then we estimated how many of them would be protected from impoverishment, or going under the poverty line, if we paid for all of their healthcare expenses plus the lodging, transportation, and food costs to get to the hospital. Those transportation and lodging costs can be more impoverishing than the healthcare costs! The longer lines in the richest/rich bars below means more richer families were protected from impoverishment than the poorest families. This means that even if we offset MOST of the healthcare and lodging/transportation costs, it only benefited the richest families. The poorest families would barely benefit at all.
So, what now? I think this isn’t an issue of individual wealth or income. This is now a structural issue, one of policies, and systems.
This bring us to the question of how do we act like a neighbor here?
Part of it is recognizing who is on the ‘side of the road’ today at an individual level. And/Also, recognizing that at a country-level too. My recent book goes into detail on what that means. A small summary is we need to recognize the systems, structures, and policies surrounding people (or the lack thereof!) that make it hard for families to get to care when they need to.
If you’ve read my book, you know I talk a lot about the And/Also of neighboring.
I think the GS story shows us the and/also of neighboring. So, what made that man stop while the others didn’t? What was in his heart that intrinsically made him stop and not just do the minimum of giving to a food pantry or sponsoring a child, which are all good work? This story shows us the and/also of neighboring. Giving food to a food pantry or donating money AND/ALSO living the rest of our lives that reflect one of neighboring.
Protecting families at an individual level from poverty AND/ALSO making sure there are systems and structures around them at a country level to do the same.
These systems include universal health coverage for all, especially those at risk of impoverishment, and bolstering up healthcare systems where the need is greatest. Nearly 50 percent of the world’s wealth is held by only 1 percent of the richest people in the world. A vast majority of the world’s doctors and health systems are located in HICs. And these system and country-level decisions have ramifications to the families living there.
So, I don’t think we need more money. We need more equity. We need to think and act more like a Good Samaritan rather than individualistic. This might shake our capitalism-trickle-down-US views, but it also leads to the And/Also of neighboring.
Happy Neighbor Tuesday, friends!
PS: In my book, I have an entire chapter dedicated to structural violence, another to challenging trickle-down economics, and another on health equity and Jesus (including me being called a Socialist in church). If you like this post or want to know more, check out the book and the 24+ pages of references. =)
-Emily