Healthy Cities in the SDG Era

8. No Poverty

September 09, 2021 Centre for Global Health, Dalla Lana School of Public Health Season 1 Episode 8
Healthy Cities in the SDG Era
8. No Poverty
Show Notes Transcript

Sustainable Development Goal 1:  No Poverty, focuses on ending poverty, in all of its forms, everywhere.

Lincoln Lau, currently based in Manila, Philippines received his PhD in infectious disease epidemiology from the University of Hong Kong. He then started working with International Care Ministries in 2013 and has led the development of their research capacity and projects. His work covers a wide variety of topics including public health, development economics, faith-based programs, social networks, and early-childhood education. He is concurrently an Adjunct Assistant Professor at the University of Waterloo and an Assistant Professor (Status Only) at Dalla Lana School of Public Health, University of Toronto.

James White RN, MSc, PhDc is the Director of the Infectious Diseases and Global Health Security Center at Abt Associates where he leads and support numerous global projects focused on epidemic preparedness, emergency response, health system strengthening, and health systems resilience.  He is a registered nurse with nearly 20 years experience supporting global communities in addressing critical issues such as infectious disease prevention and treatment, maternal and child health, emergency response, and social welfare in resource-constrained environments.  James is also a current PhD candidate in Nursing and Public Health at the University of Toronto where he is in the final stages of conducting a study focused on diagnostic assessment of states of impoverishment.  His research, aims to develop a diagnostic measure of poverty that can help clinicians infuse an understanding of political economy and critical social theory into everyday clinical practice.

CREDITS: This podcast is co-hosted by Dr. Erica Di Ruggiero, Director of the Centre for Global Health, and Ophelia Michaelides, Manager of the Centre for Global Health, at the Dalla Lana School of Public Health, University of Toronto, and produced by Elizabeth Loftus. Audio editing is by Anwaar Baobeid. Music is produced by Julien Fortier and Patrick May. It is made with the support of the School of Cities at the University of Toronto. 

Ophelia Michaelides [00:00:08] I'm Ophelia Michaelides and this is healthy cities in the SDG era, a podcast about the Sustainable Development Goals and how research conducted by faculty and students at the University of Toronto is helping to achieve them. We're recording from Toronto or Tkaronto, which for thousands of years has been the traditional land of the Heron Wendat at the Seneca and the Mississauga's of the credit. Today,  this meeting place is still the home to many indigenous people from across Turtle Island and we are grateful to have the opportunity to work on this land. In this episode we'll look into SDG 1, which focuses on ending poverty in all its forms everywhere. The United Nations has established several SDG one targets, one of which aims to eliminate extreme poverty that is living on less than $1.25 per day for all people everywhere. In contrast, the World Bank measures extreme poverty as living on less than a dollar 90 per day. The UN's targets also encompass having the number of people living in poverty along all its dimensions, implementing appropriate social protection systems for all, building the resilience of the poor, and reducing their exposure and vulnerability to social, economic, climate related extreme events, environmental disasters and shocks by 2030. Prior to the onset of the COVID 19 pandemic, countries were not on track to end poverty by 2030, while the number of people living in extreme poverty declined from 36% in 1990 to 10% in 2015. Poverty reduction has been decelerating. Over 700 million people live in poverty, and COVID 19 has pushed an additional 120 million people into extreme poverty, most of which reside in low and middle income countries. This is the first time poverty has increased globally in 30 years. COVID 19 has especially exacerbated the risk of socioeconomic marginalization for groups such as women, older people, black, indigenous and people of color, people living in extreme poverty and other groups living on the margins. In our first discussion will speak with Dr. Lincoln Lau about the nuances involved in employing poverty reduction interventions used in high resource settings to low and middle income countries. We will also explore the nature of conducting research within low and middle income country contexts and how resource constraints impact every stage of the research process. Finally, we will discuss the impacts of COVID 19 on working with low and middle income country contexts. In the second part of the episode, we will discuss with James Waite that the ways in which the definitions and the purposes of measuring poverty differ depending on who is measuring it. We will also explore the challenges of measuring poverty and the importance of using a multidimensional approach to contextualize it. This episode's discussion will focus on the importance of understanding poverty as a socially produced outcome and the significance of understanding the nuances in low and middle income country contexts when implementing context specific strategies to reduce poverty, especially during the COVID 19 pandemic. 


Ophelia Michaelides [00:03:32] Lincoln Lau, currently based in Manila, Philippines, received his Ph.D. in infectious disease [00:03:37]epidemiology [0.0s] from the University of Hong Kong.  He then started working with International Care Ministries in 2013 and has led the development of their research capacity and projects. His work covers a wide variety of topics, including public health, development, economics, faith based programs, social networks and early childhood education. He is concurrently an adjunct assistant professor at the University of Waterloo and an assistant professor at the Dalla Lana School of Public Health, University of Toronto. Welcome, Lincoln. Thank you for being with us today. I'm really looking forward to learning more about your research. 


Lincoln Lau [00:04:15] Thanks for having me. 


Ophelia Michaelides [00:04:16] Before we dive in, my question to you is, could you start us off by telling us a little bit about poverty? How do we define poverty? 


Lincoln Lau [00:04:26] Sure. Absolutely. And I think that, you know, this is such a loaded topic, but then it's also one that a lot of work has been done to simplify it. And I think probably for many of us, the first time we engage with poverty literature is by self-reported income. So the World Bank is probably one of the biggest organizations that has used this definition for a long time. It started at $8 per person per day. This is self-reported income. And then over the last couple of years, it's been raised to a dollar 25 and now it's at a 1.90. But this is kind of the crude measure that's been used to draw this line. And it's not perfect. I don't think the World Bank thinks it's perfect as well. But it's this indicator that's being used globally to set this rough line, to say that people living under this line really are in dire need of help. And then not to say that people just above the line don't need help, but it gives attention to the issue and and helps set goals and priorities and focus. 


Ophelia Michaelides [00:05:36] Thanks, Lincoln. That's really helpful. And I would imagine that the way that we define poverty impacts our understanding of poverty and how we design interventions to address them. Does this resonate with you? 


Lincoln Lau [00:05:50] Absolutely. Absolutely. And I I think that I started off by saying that the income poverty line is helpful for us, but it is still quite crude and it's simplistic in design, but it can also, in some ways it doesn't really define or describe the full issue in the way that I think it deserves to be. So there's a lot of other work that's been done to really look at poverty from multiple dimensions. So there's, there's some famous work done by Amartya Sen looking at it from a deprivations idea, and there's frameworks that have been put out by, for example, the Department for International Development from the U.K. And we're starting to look at and think through poverty, not just as income, the lack of income and finances, but there is a social aspect. So there's relationships and access to information. There is a human aspect. So maybe that's lack of health or lack of education, lack of training, lack of opportunities, and all these different types of deprivations mixed together. And we end up needing to address poverty, not as a simplistic single, you know, easy to define. It's just the the issue of not having enough income, but it's actually very multidimensional. It crosses multiple fields, dimensions, different spheres of life. Even. So, that really has been what has impacted when we start thinking about interventions to deal with poverty or to interact and address poverty, it really sets the scene, I think, in a more accurate way that when we're starting to look at interventions, it's not just about making sure people have more money in their pockets or their bank accounts. It's the idea of all of this needs to be dealt with, all of this needs to be addressed. 


Ophelia Michaelides [00:07:50] Such complexity in a deceptively simple word, I would say from what I understand, Lincoln, you are living in the Philippines at the moment and carrying out your research. I'm wondering if you could tell us a little bit more about the work that you're doing there and perhaps share with us your experiences in conducting research in the context of a low and middle income country such as the Philippines, and how this impacts the research that you are doing. 


Lincoln Lau [00:08:18] Yeah, so I've been in and out of the Philippines for almost a decade now. I first probably visited ten years to this day and then been making frequent trips for the first six seven years between. Canada and the Philippines. And then the last two and a half years, I've decided to make this home. And I think, to be very honest, I really believe that has helped shaped my perspective of what poverty is and what is it like to or what is a lower middle income country like. And I appreciate that there's times when we should address poverty and lower income as something simple, something that can be described with a few indicators or a few descriptors. But when I'm here and maybe spending more time in the setting, I start having to appreciate that it is very, very complex at the same time. So one of the things that I feel like I'm reflecting on quite often is that there is a very, very real complexity because of just there's history involved with why this is a lower middle income country, there is international relations involved and trade and climate. And, you know, the list goes on and on. But there's also this simplicity where we see broken systems at times inefficiency in processes and how things are done. And then just the reality that there is a significant proportion of the population here that doesn't have enough income to afford the things they need at home or to afford health care or for food. And all of that has really impacted my not I don't want to make it sound too easy like that. It affected my ability to do research. I think it's affected more than that. It's affected how we approach projects. It affects how we frame our research. It affects how we and I think it should affect how we approach participants and respondents and interventions and topics. So in some ways, there are projects that I'm working with where poverty is the target. You know, the intervention is designed to address a certain poverty indicator or a certain deprivation. And then there's other times where the the deprivation is not necessarily the outcome, but then poverty is interacting with every single step of the way. So we see it from the most simple things, the road getting to the study site and I hate to say it, I think this is where we also see inequality systematically continue, is that for foreign projects, sometimes we end up choosing study sites that are easier, easier to get to. And there's this reality that the poorer places end up being the places harder to get to. So all of this set play and all of this, I think makes poverty such an entrenched issue. And this is probably the complex side of what it means to work in a lower middle income country to try to navigate some of these complexities and barriers. 


Ophelia Michaelides [00:11:38] Such an important and sobering perspective to to be grounded in that context as you do research, I only imagine that the COVID 19 pandemic has exacerbated many of these challenges that you describe. I'd be interested in hearing more about how COVID 19 has impacted perhaps your research, specifically, including the communities that you work with and in in thinking about all of this, whether you've had time to reflect on lessons learned for, for instance, public health researchers or policymakers or even governments in reflecting on the current COVID 19 situation. 


Lincoln Lau [00:12:21] Yeah, so maybe I'll start with maybe a personal reflection and then also a kind of work related research type of reflection. But I think as I've spent more time thinking through what has happened over this last year, COVID 19 lockdowns, I fully appreciate that every country has gone through and everybody has gone through their their own experiences of difficulty. But I feel that maybe just for my personal reflection, there has been times when I felt living in a lower middle income country with a weaker infrastructure, with a government that maybe makes decisions in ways that are not fully transparent. Some of the the some of the actions that were taken were very, very aggressive to the point where we saw violence in some of the communities to keep people at home. I feel the mental strain, and that is just this very real consequence, I think, of living in in a country that might not. As well-resourced and might not have the same number of experts on different panels or the same police force and health care and all of that. I think I was surprised and I'm still surprised when I reflect that there was really a personal toll that I felt. And when the lockdown started to ease up in this country, then I also felt my own mental state changed. So not that I understand what it is to live in poverty, because I really think that I don't I I'd be first to admit that I don't have firsthand experience of that at all. And it's a very it's a I, I think it's a very, very different situation. And the challenges are much more. But it was it was quite sobering to feel that, you know, this affects me also. I'm not protected from it. I'm still kind of at the mercy of this wider country and context around me. So that's that's kind of from a personal side, but from a research side, I think there's many different things that we noticed. One of them that we noticed as a team was just the response that a country like the Philippines was put into the situation that we were put into because of COVID. So we're not really a low income country in that, I guess bottom category. According to the World Bank definitions, we're kind of nestled in as a lower middle income country. And I, I wonder if there is some unique perspective being a lower middle income country, because we we end up with some pretty good resources. We have you know, there's some private hospitals here that are very expensive, top of the line treatments paying out of pocket. I think the costs would be comparable to North America or Europe. And then at the same time, there's a large proportion of this country that has no access to health care at all and being in that awkward middle position. Really stirred up a lot of the lower middle class and upper middle class and just a significant proportion of the population to push the government to copy some of what's happening in the higher income countries, especially our neighbors. And there's this sense that we're close enough. We have these really nice hospitals. Why aren't we doing the same? So a lot of the news articles coming out in the Philippines early on was, "why are we not doing what Korea is doing? Why are we not doing what Singapore is doing? Why can't we do the exact same things?" And this is where I really sympathize for the Department of Health here in the Philippines and the task force put in charge of COVID response. Because we are a country with less resources, we can't do the mass testing that Korea did. We can't do the contact tracing that that Singapore did. This is an archipelago with thousands of islands. And Singapore is, you know, a small, very well defined city state. But all of these difference, I think, go out the window when when I guess the population is responding and seeing inequality, desiring what other countries have, recognizing that we don't have it and and claiming, which I think is definitely their right to tell the government, hey, why aren't we doing this as well? But one of the negative consequences was it kind of forced the hand of the government to do certain actions that maybe we couldn't afford. So that's something we've we've done some work to try to analyze and assess and to recognize that it's hang on a second. It's not necessarily true that everything that works in high resources, high resource locations should be copied in these kind of low resource settings. So there's still a lot to understand in terms of how COVID has affected countries like the Philippines in this unique setting. But I definitely see how that whole having resources and not having resources, having a significant part of the population in poverty affects the response and it affects that in a very significant way that needs to be addressed and probably wasn't done. It wasn't easy to do that in a nuanced way, especially in the acute phase of the of the pandemic. 


Ophelia Michaelides [00:18:01] Thank you for bringing forth this really important perspective. And I think it's a it's a really good reminder to the global health community around how we must be sensitive to these very important nuances and inequalities that exist not only between countries, but within countries as well. And those need to be taken account, obviously, when mounting, you know, very context specific strategies, whether it be against COVID 19 or otherwise. Lincoln, thank you so much for sharing your your personal thoughts, your professional thoughts on something that's really important and for sharing the incredible work that you're doing right now. On behalf of the Center for Global Health, we want to thank you for joining our SDG podcast. It's been such a pleasure. 


Lincoln Lau [00:18:47] That's great. Thank you for having me. 


Ophelia Michaelides [00:18:56] James White is the director of the Infectious Diseases and Global Health Security Center at ABT Associates, where he leads and supports numerous global projects focused on epidemic preparedness, emergency response, health system strengthening and health systems resilience. He's a registered nurse with nearly 20 years experience supporting global communities in addressing critical issues such as infectious disease prevention and treatment, maternal and child health, emergency response and social welfare in resource constrained environments. James is also a current Ph.D. candidate in nursing public health at the University of Toronto, where he's in the final stages of conducting a survey focused on diagnostic assessment of states of impoverishment. His research aims to develop a diagnostic measure of poverty that can help clinicians infuse an understanding political economy and critical social theory into everyday clinical practice. Hi, James. Thank you for joining us. 


James White [00:19:54] I feel it's nice to be with you. 


Ophelia Michaelides [00:19:56] It's fantastic to have you with us. I'm really looking forward to learning more about your very important work and exploring the different ways in which we conceptualize poverty. So James, to begin, we hear a lot of facts and figures around and about poverty. You know, X amount of people are living below the international poverty line or poverty rates are going up or down in y regions of the world. Now, what do we mean when we are talking about these measures? How is poverty measured and who is measuring it? 


James White [00:20:31] Great. Thanks, Ophelia, for that question. So I think to start with, we need to think about a basic question what is poverty? Before we start measuring it, we have to define what we mean by it. And looking back to some of the earliest formations of human societies in hunter gatherer societies, we see early dividing lines being created in the way that resources were shared, whether that's a animal that's been killed for food, whether that's a better shelter, or whether that's a closer spot to the fire. These early rewards were doled out to members of society on an unequal basis based on early dividing lines that were created. At that time, it was based on physical size, based on reproductive success, based on other factors of contribution toward the society. And as we've evolved through the Industrial Revolution, as our technologies have advanced, as we as a society have, quote unquote, become more advanced, those dividing lines have remained very much the same. And although the factors by which we define the poor have slightly changed the ways in which those dividing lines separate the resource share of our societies has not. The second part of your question refers to who is doing the measuring, and so it differs. It depends on why you're measuring it, for what purpose? If it's to compare relative poverty across countries, then certainly the international poverty line can serve some use. Different international organizations have different measures of poverty and poverty lines for different purposes. Different countries define poverty differently. So who's doing the measuring? It really depends on also why they're doing the measuring. And the measure that they're using can range from from what we call uni dimensional to multidimensional measures. 


Ophelia Michaelides [00:22:32] James It strikes me how long the concept of poverty has been around in our social units as humans, clearly for a very long time, hunter gatherer societies. And who knows how far before that as well. Clearly there's there's a lot to unpack around poverty. It's a deceptively simple word, even just considering what you've begun to explain to us, I imagine there are many challenges in measuring poverty, particularly, you know, you mentioned different dividing lines and different different organizations or structures measuring poverty itself. I'm wondering if you could help us understand a little bit more about the challenges in measuring poverty. What are the various dimensions? How are they measured? And what are the the barriers or the challenges that we face when we do this? 


James White [00:23:31] Great. Thanks, Ophelia. So I think one of the first challenges is defining, obviously, who is poor. Once we have decided what is poor, then we must decide who is poor. And really, the first measure attempts to measure poverty emerged around the time of England's poor laws in their effort, as the welfare state emerged in their effort to define who is deserving poor versus undeserving poor. And at that time, and for quite a few years following that, the most basic measure was along a financial line along the measure of material wealth, whether that be finances and currency itself, or whether that be other possessions of material wealth. But for a very long time from England's poor laws through to to the Industrial Revolution and so on, attempts to measure poverty were largely uni dimensional, focused on money, money centric economy, economy focused toward the 1980s and the late seventies. Throughout the 1980s, it became increasingly clear and more academically accepted that of course, poverty exists along many other dimensions of a human life that go that include but go well beyond money. And so you'll you'll you'll be familiar with measures such as the Human Development Index. You'll be familiar, perhaps, with some of the work out of the Oxford Poverty and Health Institute's work. You know, there have been attempts. Amartya Sen Work is a very good example of attempts to define the dimensions of a human life that one can be poor in. However, multidimensional measures, even for themselves and for their own purposes, have for practical purposes, you know, limited some of those, those dimensions. So we see typically a multidimensional measure often arrives at still some sort of score, some sort of you need dimensional measure. So one of the criticisms of any poverty measurement is that, you know, it doesn't know necessarily what it is measuring. It needs to define why it is measuring it. And if it's going to be multi-dimensional, it needs to avoid arriving at a score at a uni dimensional output. 


Ophelia Michaelides [00:25:57] From from listening to you. Even in the first 5 minutes of our conversation, certainly a much more complex and dynamic image begins to appear and emerge around. You know how we conceptualize poverty. And having said that, it seems to me that many of the the structures are the tools that we are using globally to track change in this field. Don't quite capture that complexity. That's what I'm I'm getting from this. And I'd be curious to learn more about the work that you are doing at the moment and how your research will contribute to a more multi-dimensional approach to understanding and measuring poverty itself. 


James White [00:26:37] Sure. So I think I first want to highlight that I'm a clinician, I'm a nurse by background. I focus on on health. I focus on human welfare. And as a nurse, you know, we've always been trained to to think holistically about health. But the other truth about my field is that nurses, clinicians, clinical providers are not often trained to think about political economy. We are not we are trained to think about the human body, not the way in which the world is hurting the human body. So my work focuses heavily on the fact that, in my belief, poverty, along whatever dimension you measure, someone to me can be poor because they don't have the ability or the physical capability or the the social support necessary to pursue their their rightful pursuit of life fulfillment. People can be poor in ways that are extremely complex. And as a clinician, I believe that those impoverishment, those deprivations are produced. I believe that similar to the way an external toxin creates cancer in the body, that external systems external violence is committed against people, external impoverishment. These are created social conditions. And therefore, if poverty is a condition, then as a clinician, I should believe that it can be diagnosed more appropriately. And so I work in the work with Lincoln, who I know will be a guest on this podcast as well. My work with the University of Toronto and in fact throughout my professional career has been focused on trying to understand how to measure poverty as it exists in a human life. How does it impact you, Ophelia? How are you feeling? Poor. How are your family members feeling poor? How is our society feeling poor during a time of pandemic? I think we can all see the ways in which impoverishment and deprivation touch everyone. And so as a clinician, my goal in our work or in my Ph.D. work and beyond is to diagnose it more appropriately so that we as clinicians and we as family members and supports to each other can can help each other [...] Deal with our deprivations. 


Ophelia Michaelides [00:29:19] Thank you, James, for your thought provoking work and research on impoverishment. I find it particularly interesting that many of our views of impoverishment itself can be at times to be seen as separate from our views from health. And what I'm hearing a lot from your work is that this is not the case. These are, you know, social constructs and a false dichotomy, essentially. And it's really important to take that holistic view um, when we when we are thinking about these concepts and you know, how to live better and how we can create a world where that can be done. James, I want to thank you so much for helping us unpack such an important and undoubtedly a very complex topic. I definitely learned a lot today, and I want to thank you for being on our podcast. 


James White [00:30:13] Thanks so much, Ophelia, and thanks for putting this podcast together. I know we as both academic community, but also just as as fighters against poverty, you have a lot to learn from from these these podcasts. Thanks so much. 


Ophelia Michaelides [00:30:35] This episode has stressed the significance of understanding poverty through a multidimensional lens that considers the human and social aspects of deprivation rather than a strictly economy centric view. This view is critical for informing holistic strategies and interventions to accurately measure and address poverty within a low and middle income country contexts. It is paramount that the global community is sensitive to the inequalities that exist between and within countries when translating interventions and strategies from high-resource contexts to low-resource settings. Understanding the social, economic, political and historical context of the country is also essential to implementing context specific strategies. The road to SDG 1 should take these factors into consideration to effectively eliminate poverty for everyone among all its dimensions. 


Ophelia Michaelides [00:31:25] Healthy Cities and the SDG era is made with the support of School of Cities at the University of Toronto, whose mission is to bring urban focused researchers, educators, students, practitioners and the public together to explore and address complex urban challenges. We would love to hear your thoughts on healthy cities in the SDG era. If you enjoyed this episode, please rate, subscribe and share to help others find the series. You can find Healthy Cities and the SDG era on Spotify, Apple Podcasts and the Dalla Lana School of Public Health YouTube page, as well as our Center for Global Health's website. Join us for our next episode where we'll look at SDG for quality education. Thank you for tuning in and we look forward to speaking soon. Take care.