In our interconnected world, if we want to be safe, we need to protect those most vulnerable among us.

The family of economist Amartya Sen befriended the great literary Nobel laureate, Rabindranath Tagore. It was precisely Tagore who gave the newborn Sen the name Amartya, which means “immortal” in Bengali, not knowing that he was witnessing the birth of another Bengali Nobel laureate. Leaving India and working at Cambridge and Harvard universities, Amartya Sen became an expert on issues of social assistance to the poor and economic and social justice. He worked out ways to assess the status of the poor, who made up half the world’s population a mere three decades ago. He was awarded the 1998 Nobel Prize in Economics for his contribution to welfare economics.

In his work “Development as Freedom,” Sen recognised five different types of freedoms. Political freedoms included the participation of the people in government; economic, the existence of a free market; social, access to healthcare and education; the freedoms he called “guarantees of transparency” included trust and mutual understanding of the interactions between people; and security, preventing any unwanted or tragic consequences for the poor. An important insight of Amartya Sen’s is that the five freedoms mentioned should not be just distant goals, but the most effective means of developing poor countries. Therefore, they should be built into the beginning of all reforms, and not merely expected as the result of them.

Personally, over the past two decades, I have witnessed the incredibly rapid economic development of a large number of countries that were hitherto very poor and burdened with very difficult problems. Private ownership, the acceptance of foreign investments, freeing of their markets, the introduction of real competition and large infrastructure projects have lifted billions of people out of extreme poverty and led to mass urbanisation, as well as the creation of a middle class even in African countries. Many countries around the world have achieved rapid economic growth and improved living conditions for most of their inhabitants through these means.

But there are always those who can’t join that race because they are dependent on someone else’s help, but not through faults of their own. Many people are born with severe illnesses that require constant care; some are prevented from enjoying normal growth and development; some did not grow up with enough food, some didn’t have the opportunity to go to school; some did not have drinking water available to them, so they spent their youth suffering from severe infections; some grew up being orphans because their young parents died of AIDS; some grew up as children in war zones or refugee camps; some were victims of discrimination, or were sold into slavery to save the rest of the family; and some, over time, due to personal misfortunes, remained handicapped. There are still many helpless and dependent people in the world today, and they need to be brought closer to other people through equality of opportunity. They need help to make the most of their lives in the 21st century. Recognised in the global development literature as the “bottom billion,” they are the most difficult problem of the global community today. Can they be helped in any way?

One solution was proposed by a third Bengali Nobel laureate, Muhammad Yunus, a social entrepreneur, banker and economist from Bangladesh. Back in 2006, he was awarded the Nobel Peace Prize for founding the Grameen Bank, which gave the most vulnerable in society so-called “microcredits”. These were small sums of money that would allow them to start very simple businesses, such as making souvenirs, sewing scarves or making wicker furniture. Commercial banks would never grant credit to such people because of their poverty. Yunus noted that borrowing even minimal amounts of money can have a disproportionately large impact on the lives of the most vulnerable, allowing them to break out of the vicious circle of poverty through their very own work.

The spread of the microcredit concept to other countries and more rigorous scientific evaluation of it showed in later years, however, that the first results of microcredit sharing were probably overly optimistic — spreading relatively rare success stories, most often related to female microcredit recipients. Nevertheless, this scientific evaluation also highlighted a previously unrecognised value.

Access to financial services is as important to the poor as the availability of electricity or drinking water is. Not having a bank account makes inclusion in modern life almost impossible. The poorest need that bill more than others, because their income is not only very minimal but also extremely irregular. Bank accounts allow them to store their money safely, so they can access it during times when it is needed the most, such as for weddings, funerals, or in the case of illness, without fear of it being stolen from them by someone even poorer than they are. A bank account, therefore, will not solve the problem of their poverty in itself, but it will certainly help to make their lives less difficult than they already are.

* * *

In 2018, I paid a working visit to India and Bangladesh, to the places where these three Nobel laureates — Tagore, Sen and Yunus — grew up and worked. Until that trip, I had a certain degree of scepticism about the claims that climate change can indeed have a very big impact on people’s health and well-being. However, after my trip to one of the areas where the “bottom billion” people live today, and where I saw the first real climate refugees in their hundreds of thousands, I will think differently about this issue.

Travelling the world as part of one’s profession and talking to many people in their local environments eventually helps to gain a pretty good sense of where the world is developing nicely, in a controlled way, and where some difficult problems began to arise. Bangladesh is home to 163 million people, which is practically half the population of the whole of Europe, and they are squeezed into an area only slightly larger than Greece. By 2002, their Gross Domestic Product had stagnated around an extremely low 400 US dollars per capita per year. But since that period, they have recorded very strong and continuous economic growth, and by 2015, they had already exceeded 1,350 US dollars. Although there are so many people in such a small space, they even manage to export large quantities of food.

However, in two geographical areas within their country, the population of Bangladesh has begun, for the first time in its recent history, to record a decline in the population. The cause of such demographic trends in the country is not a decrease in the number of births or increased mortality, but mass emigration. Bangladesh is becoming the country with the largest absolute number of emigrants: more than half a million emigrate from there each year, and in 2007 and 2008, that number grew close to one million. Emigration is now approaching the figure of ten million people and about 15 billion US dollars a year is sent back to Bangladesh, which is a tenth of the economic potential of this populous country.

However, given that this is a country where many people seem happy and optimistic and which, according to some “happiness indices”, is even ranked among the “happiest in the world”, then why do so many people emigrate because of strong economic growth and countless opportunities for personal progress? Well, these waves of emigrants are driven mostly from geographical areas right next to the Bay of Bengal, the so-called “the mouth of the Ganges”, where the three aforementioned Nobel laureates were active, and where all of the incredibly wide rivers of Bangladesh flow together. Many of those rivers begin their course quite far away in the north, being formed by huge amounts of melted snow and ice from the Himalayas. Their water pours down the mountains and passes first through India, flowing from east and west into Bangladesh, merging and intertwining, and then ending their path in the Bay of Bengal. These rivers are not like the ones we’re used to elsewhere in the world: the Brahmaputra, Ganges (Padma), Meghna, Jamuna, Teesta, Suma and others can be up to twelve kilometres wide and they support the lives of all of those 163 million people.

However, due to climate change, the amount of water in all of these rivers, and in general throughout the Indian subcontinent, has begun to decline in recent years. In addition, the parts of India through which these rivers pass are getting so polluted and exploited that poisoning by arsenic and other toxic substances present in the water is a serious public health issue. But the main cause of the emigration is that the reduced amount of water in the freshwater basin has led to the penetration of the saltwater from the Bay of Bengal for many miles inland. As a result, the land has become salty, and agricultural products can no longer thrive. The water in the river beds has also become salty, meaning that people drink semi-salt water, which, for example, causes them to have high blood pressure.

Still, people will do anything to adapt and survive. As a result, millions of people along the coast have retrained, going from farmers to fishermen, so instead of various vegetables and rice, they now grow, eat and export shrimp. For others, it was all too much trouble, so they began to emigrate in large numbers, becoming the first true climate refugees. The richest remain, because they can afford to remain insensitive to all changes. With them, also, those willing to adapt to change, i.e. the shrimp breeders, and the poorest, who don’t understand what is happening around them well enough, but merely continue to try to survive daily, depending on the mercy of all others.

* * *

One cannot speak of the “bottom billion” without mentioning another major crisis area, given its exposure to various risks and the fragility of the support system, i.e. Africa. In 2018, one of the world’s major cities was also hit by climate change. Cape Town, South Africa, has about 3.8 million inhabitants. Due to climate change, from 2015 to 2017 it was hit by three consecutive extremely dry years. The city’s water supplies dwindled so much that the proclamation of “day zero” was anxiously awaited there — supplies were dropping to a level where the authorities would need to turn off the water supply. They already needed to plan for the water to be distributed to millions of people daily in 25 litres per person. They expected kilometre-long queues of inhabitants hoping to get their share of water at about 150 places in the city. They came very close to this scenario, which would have meant that Cape Town would go down in history as the first major city to run out of water.

The “bottom billion” are most easily characterised as people who, in the event of any crisis which affects all of humanity to the same extent, would find it the most difficult to protect themselves and resist the challenges. They are the most sensitive, the most exposed, and the first to be hit by any common misfortune. These misfortunes can include food shortages, water shortages, adverse weather conditions, or a major infectious disease pandemic. The more we can all do together for them, to increase their prospects and their level of resilience, the more resilient and stable we will all be together, as humanity. Helping them should help us all to more easily overcome the various challenges that lie ahead of us.


Declaration: Professor Igor Rudan, FRSE, is the President of the International Society of Global Health; co-Editor-in-Chief of the “Journal of Global Health”; Joint Director of the Centre for Global Health and the WHO Collaborating Centre at the University of Edinburgh, UK.

TWITTER: @ProfIgorRudan

FACEBOOK: Professor Igor Rudan



Image credit: Ursula Gamez,

Director of the Centre for Global Health and the WHO Collaborating Centre at the University of Edinburgh, UK; Editor-in-Chief, Journal of Global Health