Fighting disease in impoverished settings also means fighting the poverty at the roots of ill health. People are far more likely to fall ill if they are chronically hungry and malnourished, as is the case with more than one-third of the people in Haiti, Rwanda and Lesotho. A Haitian proverb spotlights the connections between disease and hunger, medicine and food: "Giving drugs without food is like washing your hands and drying them in the dirt." Similarly, the risk of disease and death skyrockets when people must drink dirty water or when sick and healthy family members are crammed together in a leaky, smoke-filled hut.

Lack of food, clean water, and adequate housing also undermines treatment and impedes recovery after people do get sick. Even the best medical care may have little effect if patients are too malnourished to absorb their medicines, if they are swallowing their pills with contaminated water, or if they are living in shacks where the rains pour in. In our programs, our research and our advocacy work, Partners In Health prescribes food, clean water, and decent housing as requirements for health and well-being and as basic human rights.

Food – proven treatment for hunger and disease

The world produces a surplus of food, yet chronic hunger afflicts more than 850 million people worldwide, the vast majority of them in the developing world.

The devastating impact of hunger and malnutrition on health and medical care cannot be overestimated. People whose bodies and immune systems have been weakened by hunger are far more likely to fall ill, far more likely to suffer serious or fatal complications when they do, and far less able to benefit from treatment. Medications are often less effective or difficult to take on an empty stomach; travel to clinics becomes impossible due to weakness; work time cannot be spared for medical visits.

Every year 6 million children die from causes related to hunger and malnutrition. Community-based studies of children under the age of five have found that being hungry and underweight causes more than 60 percent of deaths from diarrhea, the biggest killer of children after neonatal disorders. Deficiencies in specific nutrients such as iron or vitamin A also weaken the body’s ability to fight disease and multiply the risk of death from common childhood diseases. Vitamin A deficiency, for example, increases the risk of death from diarrhea, measles, and malaria by 20 to 24 percent.

Hunger is particularly dangerous for people with consumptive diseases like AIDS and tuberculosis that significantly increase nutrient requirements and cause crippling loss of weight, strength, and energy. Symptomatic HIV patients require 20 to 30 percent more calories than HIV-negative people of the same age, sex, and physical activity level. People living with HIV need more food, but they usually get less. A PIH study in rural Haiti found that HIV-positive patients were nearly 10 times more likely to have limited the number of times they ate and 12 times more likely to have passed a day without eating in the previous month than HIV-negative or untested individuals.
People living with HIV infection who grow much of their own food may lose productivity, income, and their personal food supply when they fall ill. In turn, a lack of food only worsens HIV disease, increases the risk of opportunistic infections, and hastens the onset of full-blown AIDS.

At PIH project sites, clinicians and community health workers evaluate patients’ needs and identify those who require food support to improve the effectiveness of medications and alleviate the burden of hunger. For many years, Zanmi Lasante in Haiti has emphasized malnutrition programs for children and has provided nutritional support for patients being treated for AIDS and TB. In June 2006, ZL teamed up with the World Food Program to begin distributing food to an additional 2,500 patients and their families. ZL also supports daily school lunches for more than 6,000 children in central Haiti in partnership with 21 local schools. Each month in Rwanda, more than 1,200 patients and their families receive food baskets filled with nutritious staples such as rice, beans, and vegetable oil.

In publications and at conferences around the world, PIH advocates for increased access to food assistance and fair trade policies, amplifying our patients’ call that hunger causes and complicates many of their illnesses and that food is the proven cure for hunger. At the 2006 International AIDS Society Conference in Toronto, PIH focused on “the food fight” through interventions in several conference sessions, a joint press conference with the World Food Program, and a poster session reporting on ongoing research into “pervasive food insecurity as a major factor in the care of patients with HIV.”

Clean water – key to saving 3 million lives a year

Access to clean water is a basic human right and a prerequisite for improving the health of poor communities. Yet an estimated 1.1 billion people around the world, almost four times the population of the United States, do not have access to safe water. Almost all of them live in developing countries and two-thirds subsist on less than $2 per day.

The costs of lack of clean water to health and to economic and social development are incalculable. Diseases spread by unsafe water cause 3 million deaths a year. Young children are the most likely to suffer and die from these diseases. Diarrhea, primarily a disease of dirty water, is the biggest killer of children under five in poor countries, resulting in nearly 4,000 preventable deaths each day, 1.8 million per year. At any given time, almost half of all people living in developing countries are suffering from a health problem caused by lack of safe water and sanitation that undermines their ability to study or work. Every year, children miss more than 443 million school days because of water-related illnesses.

Water projects are one of the most effective ways of saving lives and one of the most cost-effective investments in disease prevention. Potable water projects typically reduce diarrheal disease by 30 to 50 percent, with even higher reductions during water-borne epidemics, such as cholera and typhoid. The World Health Organization estimates that every $1 invested in water and sanitation yields between $3 and $34 in reduced medical costs and increased productivity, depending on the region.

The U.N. Development Program calculates that closing the gap between current trends and the Millennium Development Goal target of reducing by half the proportion of the world’s people without access to safe water and basic sanitation would save more than one million children’s lives over the next decade and bring total economic benefits of about $38 billion annually. The benefits for Sub-Saharan Africa—about $15 billion—would represent 60 percent of the total amount the continent received in the form of foreign aid in 2003.

PIH has long recognized what our patients have been telling us and their medical records confirm – dirty water is a major cause of preventable disease and death, as well as of demands on clinical resources. About one-third of all Haitian children die before they reach the age of five, with 60 percent of all these deaths directly related to malnutrition and diarrheal disease. To Haiti’s poor majority, the lack of clean water is not only an environmental problem, but a matter of life and death.

In 1985, with the help of engineers from South Carolina, Zanmi Lasante brought clean water to the village of Cange—home of the Clinique Bon Sauveur—by establishing a major hydraulic system. In one fell swoop this project eliminated child deaths caused by diarrhea in Cange. ZL has learned that while many of the challenges to improving health in Haiti would take decades to address, making clean water available can save and improve lives right away. During the past two decades, we have worked hard to achieve this goal, constructing and repairing more than a dozen water systems in several towns and villages in Haiti’s Central Plateau.

Housing

For hundreds of millions of the world’s poor, home is not a place of comfort but an incubator for disease and despair. The U.N. Human Settlements Program estimates that more than 1 billion rural dwellers and 600 million urban residents in developing countries live in overcrowded housing with poor water quality, lack of sanitation, and no garbage collection. Roofs and walls of scavenged materials do not protect from rain, wind, pests, or intruders. Dirt floors turn to mud in the rainy season, putting those who cannot afford shoes, chairs, or a bed at greatest risk. Smoke and heat from open cooking fires cause respiratory ailments and severe burns in children.

Housing affects health in many different ways. Deficient housing can compromise the most basic needs of water, sanitation, and safe food preparation and storage, allowing the rapid spread of communicable and foodborne diseases. Other problems, such as poor temperature and humidity regulation, can lead to respiratory disease. Overcrowding greatly increases the risk that when one person falls ill, the disease will spread rapidly to other members of the household.

PIH’s housing programs uphold the right of the poor to safe, sturdy housing. Zanmi Lasante’s Program on Social and Economic Rights (POSER) has constructed simple, decent homes for more than 250 families in rural Haiti. ZL’s program of housing rehabilitation, renovation, and construction gives priority to the needs of patients living with HIV or tuberculosis and their families, whose medical and economic needs are often greatest. Based on the success of the housing project in Haiti, Inshuti Mu Buzima, PIH’s partner organization in Rwanda, launched its own POSER program at almost the same time that it began enrolling patients for antiretroviral therapy. Within a little over a year, the program was building an average of almost five houses a month.