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By Anirudh Krishna


The Montréal Review, November 2011


 "One Illness Away: Why People Become Poor and How They Escape Poverty" by Anirudh Krishna (Oxford University Press, 2011)


"The outcome of a decade of work in five countries, and the result of conversations and surveys with more than 35,000 families, one of [the book's] chief goals--and accomplishments--is to flesh out our understanding of economic deprivation."

--The New York Times

"Many studies of poverty deal with it as a statistical phenomenon, but this book is different. Krishna is a brilliant scholar who has spent considerable time in the field. He is aware that no panaceas or quick fixes exist, but he develops an ingenious approach to helping people out of poverty. This is a must-read for graduate students and policy makers alike."

--Elinor Ostrom, Nobel Laureate in Economics 2009 and Co-director of the Workshop in Political Theory and Policy Analysis, Indiana University


Is it possible to prevent or forestall poverty? How many among the poor of today were not born poor - but fell into poverty? How could their descents into poverty have been stemmed before they occurred?

What about those who rise out of poverty? Do they only become marginally non-poor? Or have some actually become rich?

Over six years, from 2001 to 2007, I explored these two sets of questions in four developing countries (India, Kenya, Uganda, and Peru) and one part of the United States, interviewing a total of 35,000 families.

Not all of these families are poor, to be sure. Many have never been poor. Others escaped poverty. Still, a significant chunk was found to be poor in each context. They could not afford basic necessities, such as food, clothing, reliable shelter, education for their kids.

Among the poor, more than one-third were not born to poverty. They became chronically poor within their lifetimes. Accounts such as the following were common to hear.

We were among the more prosperous households of our village. We owned land. We also owned many heads of cattle. But things changed for the worse, and today we are among the poorest people in our village, the recipients of community handouts on religious holidays.

Narrated by Heera Gujar, a farmer in India, this account of descent into poverty was saddening. But it was hardly peculiar or rare. No matter where I went, I encountered such instances. In richer communities and in poorer ones, in countries with faster and slower rates of economic growth, deep in the interior, but also in small towns and bustling capital cities, the problem of descent into poverty was widespread and serious.

How do people become poor? Here is what Heera had to state.

The bad days began when my father fell ill about 18 years ago. They say he was stricken by TB [tuberculosis]. We took him several times to the district hospital, about 35 kilometers away. Each time we spent a considerable amount of money. We must have spent close to 25,000 rupees on his treatment, but to no avail. When my father died, we performed the customary death feast, spending another 10,000 rupees. We sold our cattle, and we also had to take out some loans.

We worked harder in order to repay these debts. Then, about ten years ago, my wife fell seriously ill, and she has still not recovered. We borrowed more money to pay for her medical treatments. More than 20,000 rupees were spent for this purpose. It became hard to keep up with our debts. Somehow we could make do for another two or three years. Then the rains failed for three years in a row, and that was the end of the road for us. We sold our land.

Now, my sons and I work as casual labor, earning whatever we can from one day to the next. On some days, we find work. On other days, there is nothing.

No single cause accounts for Heera's descent into poverty. A combination of causes - a chain of adverse events - was involved. Other cases examined also show that people fall into poverty, not all at once, but by degrees. Multiple everyday events - illnesses, deaths, marriages, debts - combine to push people into poverty. Anyone can fall into poverty, and many do.

The majority of those who experience descents remain persistently poor. Such avoidable large-scale misery can and should be prevented.

Governments and donor agencies focus exclusively, however, on raising people out of poverty, blindsided to the parallel flows leading into poverty. Progress against poverty is marginal and becomes compromised: what is reduced with the help of policy gets restored as a result of events.

There are many opportunities for preventing the growth of poverty. Multiple links in the chains of adverse events can be broken effectively, as the book shows. Where preventive assistance has been available, many fewer people are poor. If preventive assistance had been available on a wider scale, a third fewer people would be poor today.

Different reasons are associated, respectively, with escaping poverty and becoming poor. Analyzing the life histories of thousands of people, such as Heera Gujar, who have become the new poor of the world, the first part of the book identifies reasons that commonly precipitate descents into poverty. Some among these reasons - particularly ill health and high health care costs - are common across regions and countries; others are more context-specific, requiring more decentralized remedies.

The second part of the book looks at the reverse side of the poverty equation. How many people escaped poverty? Among them, how many became rich?

The answer to the first of these questions is encouraging. Large numbers have risen and continue to rise out of poverty. But the second answer is disheartening: very few have become rich.

Those who have risen out of poverty serve mostly as itinerant laborers, maids, gardeners, lorry loaders, street vendors, marginal farmers, and the like. Much more needs to be done, not just to raise the number of poverty escapes (which is important), but also to enhance the quality of individual lives (also important, but often ignored, because of planners' preoccupation with the aggregate statistics).

Over and over, in interviews with poor mothers and fathers, I was reminded of one essential fact: poverty at the present time is not so hard to bear if future opportunities for one's children are visible and bright. But only too rarely have poor peoples' children become managers, doctors, professors, media personalities, or prize athletes. Not one among more than a hundred software engineers interviewed in Bangalore grew up in a poor household.

A wide gap persists between talent and opportunity, a gap that policy is doing little to bridge. I found many highly talented children in poor communities. (One particularly memorable kid had me running for cover, posing math questions I could not answer, after I started quizzing him in math, a quiz he aced.)

Despite abundant talent, these young adults mostly dream of becoming someday a schoolteacher or police constable. No better career pathway is visible to them, even to those who live cheek-by-jowl with rising industry.

Raising a mass of people above poverty is a noble pursuit. But shouldn't individual capability also figure in these strategies? Imagine that someone like Einstein was born poor. Would raising him to day laborer count as notable success?

Revising the objectives and strategy of poverty reduction is essential. Two parallel sets of anti-poverty policies are necessary. Waiting until after someone has fallen into poverty is hardly the only time when assistance should be provided. Preventive assistance must become the norm. In parallel, efforts must be made to substantially augment prospects for upward mobility.

Learning from thousands of individual experiences, considering both escapes from and descent into poverty, this book presents an account of what should be done in both respects. The essence of the argument is summarized in the following equation:

Poverty = frequent downward tugs + limited upward mobility

Societies' progress against poverty will depend on how they remove or reduce downward tugs while simultaneously lifting the low glass ceiling under which too many poor individuals currently live. How both these objectives can be achieved in practice is discussed in One Illness Away with the help of many inspiring examples.


Anirudh Krishna holds a Ph.D. in Government (Cornell, 2000) and a Masters in Economics (Delhi, 1980). He is Professor of Public Policy and Political Science and Associate Dean for International Academic Programs at Sanford School of Public policy, Duke University. Krishna is author or co-author of five books and more than thirty peer-reviewed articles. Before turning to academia in 1996, Krishna worked for 14 years in the Indian Administrative Service, where he managed diverse initiatives related to rural and urban development. His most recent research project, reported in this book and conducted over seven years between 2001 and 2008, examines household poverty dynamics in five countries. Krishna received the Dudley Seers Memorial Prize in 2005 for the initial work, which has also influenced future plans of diverse development organizations.


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