Health represents a real dread for people in extreme poverty. This constant anxiety comes from them having no control over their bodies or illnesses. They live in a perpetual state of extreme fatigue and anxiety, obliged to ‘work themselves into the ground’, unable to stop because of their material needs.
The warning sign is the brutal intrusion of pain. When they are in pain, only then do they stop. They only stop to pay attention to their health when there is serious pain, acute suffering, not everyday complaints. Families on one housing estate were astonished to see that a member of ATD Fourth World had to rest “just because of a sprain”. Similarly, women often consider that childbirth is not an illness (which is certainly true) and that they can continue to work in the hours that follow. Their living conditions force them to do so.
In the Fourth World, to stop requires an unusual and sudden pain, for example, a hernia, tuberculosis or cancer, all afflictions the poorest are prone to. Generally, the permanent state of tiredness, wear and tear, means that they become accustomed to the pain, no longer feel it and do not speak of it. They can not “pay attention” except insofar as they are sure there will be no disastrous consequences.
Deprived of the means to have control over their bodies, the poor go to extremes. They believe they are not worth the trouble of looking after themselves. To consent to being treated without anxiety, is it not true that you have to be sure of yourself, sure of your job, sure of your family and sure they will understand and accept the situation and will be able to organise themselves without you? For example, Mrs H., who had cancer, discharged herself from hospital before treatment had even begun as she wasn’t sure that her husband would be able to take care of the children. Wouldn’t they be placed in care, as was the case a few years ago for the same reason?
Their milieu neither understands nor accepts the onset of illness; rather it is confused by it. Moreover, in a state of extreme poverty, life is organised in such a way that you can only really rely on yourself. You cannot even rely on the person who wants to help you, as you have so many fears about them. What if the money were to be wasted? What if they spend the little you have? What if the children are left with nothing?
The same fear and lack of understanding prevail when it comes to treatment. In the Fourth World, once the pain goes away, people can no longer think they are ill or need to continue looking after themselves. Hence the frequent abandonment of treatment. Without things to remind you, without an environment supportive of your efforts, how can you persevere with treatment in a world where consistency and long-term are made impossible?
So much of the evidence we have seen makes us say over and over again that the medical world owes everyone, especially the most disadvantaged children, the joy of having a healthy body. This includes having a body that is cared for, looked after and made attractive (exercise and aesthetics), a body to be proud of and which can express so much: of being comfortable in one’s skin, of no longer being shy or afraid to present oneself or to speak out…
This is the first duty of doctors to the Fourth World. It is for them to fully implement the Charter of the World Health Organisation: The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition. They will only achieve this in the poorest communities if they are involved at grass roots level, and if they are not only medical practitioners but true educators of life and health.
In conclusion, it is clear that they must be men and women capable of creating a new health culture starting with the most disadvantaged; of creating a system of healthcare for the future which will finally provide equality in life for all human beings and especially for children.
Then doctors will no longer be the magicians from whom the Fourth World expects miracle drugs and quick results. They will be friends with whom, in confidence, we can develop our sense of freedom and wholeness, however vulnerable we might be, and with whom we can build a profound change in society that gives priority to the most disadvantaged.