What is poverty?

A few months ago, we cut down on the number of bill write offs in our rural clinic due to a heavy financial crunch. Prior to this move at least 20% of the patients who visit the clinic would have their bills written off, but now we barely waive the bills of about 5% of the patients. Before we made this decision, we went through a lot of deliberations on what would happen to the regular long term medications that these patients were taking. One great buffering system that we had in place is the Makkalai Thedi Maruthuvam scheme of NCD care at people's doorstep that is implemented by the Government of Tamil Nadu. My colleague led a state-wide evaluation of the reach and access of this scheme and her findings were encouraging. Many rural poor were now receiving diabetes and hypertension medications at their doorstep through the MTM scheme. Not only this, many people who were previously taking medicines from the private sector had converted to the public sector, thanks to the MTM scheme. So, while breaking the news that we would not be able to afford to write off their bills anymore, we were also giving letters of referral to our patients to the Women Health Volunteers and Village Health Nurses to enrol them into the MTM scheme. It has been a few months since we implemented this transition and our observations have been unique. 

Some of these patients have transitioned to MTM care. They are now receiving regular NCD drugs from the public health system. They would bring all the medicines to us and have us endorse them and sort them according to when they must be taken, into separate covers, and take them back. But many of the patients chose to stay with us. They are now managing to ration some money every month for buying their medicines from us. These patients who have now transitioned to getting the medicines from us by paying for it have been awfully quiet about it. No complaints, no fretting, no bargaining. This, instead of being reassuring and comforting, is leading to a lot of discomfort in our minds. 

Mrs. B lives in a thatched hut in a village near our clinic. She lives alone. Her daughter visits her once every 3 months from Chennai. Whenever she visits she gives her 1500-2000 rupees cash and buys her rice and other provisions that she requires. She also receives an elderly pension from the government, an amount of 1000 rupees per month. She has diabetes and hypertension and takes medicines for it. She also has psoriasis, a very severe skin disease with rashes all over the skin and intense itching. When she was receiving treatment from us, she used to buy her diabetes and hypertension medicines, but could not afford the psoriasis medicines. So we used to write off the bill partially waiving the amount she had to pay for the psoriasis tablets, ointment and oil. Since the time we stopped writing off the bills, Mrs. B has been suffering from a severe flare up of psoriasis and is unable to take treatment for it. The nearby government primary health centre does not have the medicines for psoriasis. She is unable to afford to buy them from us, and she is also unable to travel to the nearest government health facility, 40 Km away, where she can get it. Not once has Mrs. B asked us for free medicines, despite her suffering. She is suffering quietly. 

Mr. A, one more patient for whom we stopped writing off the bills, has hypertension and coronary heart disease. He is about 50 years of age and is an agricultural labourer. There is no regular source of income. He has two daughters, whose marriage he conducted by taking heavy loans from multiple sources. He is now drowning in debt and struggling to repay the interests of the loans. He was taking regular medicines from us. Now we have referred him to the MTM scheme. He gets the tablets regularly free of cost. But all the tablets look similar and are not colour coded like the medicines in our clinic. He gets confused about which tablet to take when. Sometimes he takes the wrong tablets and becomes sick and is unable to go to work. He loses that day's wage and he and his wife go hungry on those days. Mr. A continues to take the confusing pills from MTM, never once has he asked us to resume giving him medicines free of cost. 

Mrs. Y is a 72 year old lady, living with her son in an affluent area of the village near our clinic. She has diabetes and hypertension. Her vision is grossly impaired because of cataracts. She refuses to get the cataract operated. Her son is an agricultural land owner. Her son and daughter in law do not prioritise her illness or her health. They say, "just stay quiet in the room that we have built for you. You are old and your body cant tolerate surgeries or too many tablets" and procrastinate bringing her to the clinic or getting her medicines. When we were writing off her prescription, she would somehow hitch a bike ride with her grandson or some other young person in her village, visit us, get the pills and go home. When we referred her to the government MTM scheme, the community health worker is not even allowed to go near her house as her son and daughter in law perceive that it will diminish their pride and honour if their mother is seen as taking 'free government pills'. So she has now become very irregular in her medicines. She is another person who is suffering in silence. 

Yesterday during a casual discussion in the clinic, the clinic staff were saying, "Since the time we stopped giving 'free medicines' all those patients have started paying for their tablets quietly. People have money and are willing to pay, we unnecessarily think they can't afford to pay and were giving them waivers." One of the staff was saying, "we should not be giving anything free. Free goods have no value. If we charge something nominal, they will value it more". Another person was saying, "Most of the people for whom we were giving free medicines like Mrs. Y, are rich people. They were ripping us off." 

I have been thinking about this. What is poverty? Isn't it lack of access to essential and basic needs. Isn't poverty a lack of options to choose from? We tend to define poverty with money. Mrs. B had money to buy her diabetes and hypertension medicines, but did not have enough to buy psoriasis drugs. Compared to someone who does not have money to buy anything, yes Mrs. B is relatively better off. But isn't Mrs. B suffering because of inability to afford some medicines? Isn't her choice limited? Mr. A is unable to afford to get his medicines. The government welfare scheme is taking care of him. But he is unable to manage the medicines effectively. He prefers an easier method of being able to identify which tablet to take when. His choice is restricted. Isn't this another dimension of poverty? Mrs. Y belongs to a rich household. But she is seen as 'old' and as a 'burden'. So her health needs are not prioritised. Isn't she poor? Poverty is far too complex to be measured merely by the financial status of a person. This is why I am generally opposed to making objective assessments of people's financial status as part of philanthropy. Poverty is a subjective experience. Addressing that subjective experience is the collective responsibility of the society. I wish we raise enough funds to subsidise the medications for people like Mrs. B, Mrs. Y and Mr. A.