One Illness Away:
Why People Become Poor and How they Escape Poverty

Anirudh Krishna

Oxford University Press 2010
A book review by Danny Yee © 2012
If the poverty rate in a country has dropped by 5% over a decade that suggests steady progress, but the reality behind such a figure is likely to be that 15% of the population succeeded in escaping poverty while 10% fell into it. Attempting to understand such dynamics, and the processes underlying them, One Illness Away presents the results of a large-scale study that tracked the events affecting individual households, in communities in Rajasthan, Gujarat, Andhra Pradesh, Kenya, Tanzania, Peru, and North Carolina.

The study used a novel "Stages of Progress" metric for poverty. This is local, in that it varies from region to region, and is based on households' assets and capabilities rather than on income or consumption. In Western Kenya, for example, there is a regular progression of acquisitions: 1. Food; 2. Clothing; 3. Repairs to house (primarily thatched roof); 4. Primary education of children; 5. Purchase chickens; 6. Purchase a sheep or goat; and — the step that takes a household out of being considered poor — 7. Purchasing local cattle. A series of further steps are required for a household to progress to prosperity: 8. Improvements to housing, furniture; 9. Secondary education for children; 10. Buy or lease land; and 11. Purchasing dairy cattle. (This metric is retrospective and evaluated through surveys but verified using other data; an appendix explains some of the methodological details.)

Using this kind of poverty metric, rather than aggregate measures and simple-cutoffs, allows the event histories of individual households to be tracked. One basic finding is that poverty has dynamics, and that the processes by which people escape it are not the same as those which pull them back into it. "Stemming poverty creation must become an integral part of the anti-poverty agenda."

Descents into poverty are often driven by multiple negative events. By far the most significant of these, in all the regions studied, are illnesses and other health problems, which often combine loss of income with medical costs. Other events are more location-dependent, and include social and ceremonial costs such as the expenditures associated with weddings or funerals, high interest debt, and adverse agricultural events. Helping people avoid the "health poverty trap" may involve risk-pooling and social insurance, better provision and oversight, and safeguards against malpractice by providers. Other events can be tackled by collective action to, for example, cater for and/or reduce funeral costs.

The events which contribute to escapes from poverty are dominated by agriculture — the acquisition of land, technology improvements, and so forth — where positive changes are of direct benefit to near-subsistence farmers. Another key contribution to upward mobility comes from finding jobs in the informal sector (without job security, health insurance, and so forth). There is considerable variation both between households (though factors such as the education level of the household head have surprisingly little effect) and geographically, not only between regions but locally, with factors such as communication links and land quality important. Barriers to attaining prosperity, rather than just escaping poverty, include a low "glass ceiling" in the informal sector and limitations on agriculture resulting from landlessness, subdivision, and so forth.

Looking beyond the basic study, Krishna includes a chapter on "connecting capability with opportunity: investing in information", which considers the barriers to not just escaping poverty but attaining prosperity. Approaching from one direction he surveys software engineers in Bangalore, where not one of his respondents came from a poor household, and from the other direction he looks at the ambitions of high school children in villages in Rajasthan and Karnataka, finding quite a limited range of aspirations.

Krishna concludes with policy recommendations, advocating a two pronged strategy targeting both protection and opportunity. We need to understand the local context, target the reasons for poverty rather than poor people, work top-down as well as bottom-up, and continuously monitor results. "Looking for any grand or mono-causal theory of poverty reduction is a misguided enterprise." When it comes to preventing descents, Krishna sees a key role for government in health care, in insurance, quality control, and consumer protection. When it comes to equalising opportunity, he emphasizes investment in information and transport infrastructures linking people and communities to the centres of economic growth, so they can share in the benefits.

The presentation in One Illness Away is fairly dry and occasionally drawn out — there are a few places where the text effectively just repeats the data in a table — but mostly quite accessible. It incorporates ideas from both political theory and economics, but is much more engaged and practical than abstract approaches to conceptions of poverty or fiddling with numbers and metrics. Krishna also gives a human face to his account by including some short examples of individual life stories.

One Illness Away offers a revealing perspective on poverty. It should have relevance and appeal to a broad audience, not just workers in development, economists, and other specialists.

February 2012

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%T One Illness Away
%S Why People Become Poor and How they Escape Poverty
%A Krishna, Anirudh
%I Oxford University Press
%D 2010
%O paperback, notes, bibliography, index
%G ISBN-13 9780199693191
%P 229pp