Transcript Document 7612160

15 Health & Development,
Poorer Countries: Nepal
Learning Objectives
Identify factors known to be associated with
health outcomes in poor countries
Describe possible theories for why countries
end up with the health they do?
Critique the concept of development used in
reference to stages for countries
Who has traveled to poor countries:
Who has traveled to a poor country?
Who has traveled to poor countries:
Who has traveled to a poor country?
Who has lived in a poor country?
Who has traveled to poor countries:
Who has traveled to a poor country?
Who has lived in a poor country?
Experiences?
Impression of health status of people there?
HUMAN HISTORY
Descended from other primates, unclear just
where we branched off
Million year human history, give or take a few
hundred thousand years
Terms
–Hunter-gatherers, forager hunters mobile (bands)
–Prehistory: paleolithic, mesolithic (transition)
•Neolithic (cultural systems based on domesticated plants,
animals)
– tribes
gatherer-hunters or forager-hunters
for 99% of human existence
lived in small groups of 20-75
spent most of the time in leisure pursuits in small,
close-knit groups called bands
very little hierarchy, vigilant sharing
very difficult to conquer or enslave, but could be
driven out or killed
– can take their territory but not their stored resources
any human evolutionary changes resulting from
genetic drift had to have occurred during this
time
Societies from the Paleolithic to Present
Forager-Hunter society has been human’s
most successful adaptation
“Cultural man has been on earth for
some 2,000,000 years; for over 99%
of this period he has lived as a huntergatherer. Only in the last 10,000
years has man begun to domesticate
plants and animals..... Homo sapiens
assumed an essential modern form
at least 50,000 years before he
managed to do anything about
improving his means of
production.... To date, the hunting
way of life has been the most
successful and persistent
adaptation man has ever achieved.”
– Lee, R. B. and DeVote I. (1968). Man
The Hunter.
Poverty from the PALEOLITHIC to PRESENT
The world's most primitive people have few
possessions, but they are not poor.
Poverty is not a certain small amount of
goods, nor is it just a relation between
means and ends; above all it is a relation
between people. Poverty is a social
status. As such it is an invention of
civilization. It has grown with civilization
[as an invidious distinction between
classes]
– Marshall Sahlins Stone Age Economics
Egalitarianism in Human Societies
Egalitarianism product of human intentionality
– “if tendencies to hierarchy are to remain
decisively reversed, both hunter-gatherers and
people living in modern democracies must
consciously create, and carefully enforce
egalitarian plans or blueprints”
– Boehm: Hierarchy in the Forest
Antiauthoritarian Sanctions
– Moderate: criticism, ridicule or disobedience
– Strong: ostracism, expulsion, deposition, desertion
– Ultimate: execution
Gender egalitarian
Egalitarianism (natural selection)
Large forebrain needed for social skills and political
intelligence
– Intuitive actuarial intelligence (or insurance program)
– meat in large quantities is always shared (reduces familylevel variance in protein intake, band-wide sharing,
cooperative systems)
– Morality, egalitarianism, warfare
– White sclerae
– Gossiping the functional equivalent of primate grooming
Group Selection of altruistic traits (altruistic genes)
–
–
–
–
Competes with within-group selection of selfish traits
Nepotism vs altruism (vigilant sharing socially enforced)
Loss of total body erectile hair capability (weapons)
We go to war is evidence of altruistic traits
Agricultural Societies
Emerged to cope with increasing population and
decreasing food supplies from foraging
Inventions, technologies,and organization related to
agriculture usually known to societies
These technologies only adopted when necessary
and adoption goes hand in hand with social
stratification (Ester Boserup)
Less work before present "English data on farm work in the
Middle Ages show that at least in England the working days
which the peasants had to perform for the landlords lasted from
sunrise to noon only. A fair day's work seems to have been a
half-day's work."
Agricultural Societies
Anthropological studies suggest that primitive
peoples usually consider both hunting, fishing
and food collection as pleasurable activities,
while food production is resorted to only to the
extent that other and more agreeable activities
fail to provide sufficient food. The effort devoted
to food production is often seen to be limited to
the bare minimum of hours necessary to avoid
starvation. (Boserup)
Agricultural Societies
Expansive: settlement patterns changed from
bands to tribes, chiefdoms, states
Destroyed hunter-gatherer societies:
– Mostly through behavioral violence
• Bounties in USA: (£ 20 for male £ 10 for a female
or child)
– More recently through ethnocide
• Cultural: Residential Schools
– Brody’s The Other Side of Eden
Today: destruction using structural violence via
globalization but older methods of forced
resettlement still used (Kalahari Bushmen)
Agriculture
villages: of several hundred to few thousand, sharing
common language, culture, linked in loose
confederacies (tribes), or united more formally in
rank societies or chiefdoms comprising many
thousands
• safety in numbers because stored food in towns
• craft specialization emerges, so proximity improves
efficiency of specialized tasks
• farmed and stored foods become private property
• central government control more possible
civilization: communities of varying sizes, integrated
into states
Importance of POWER and power relationships
Agriculture
fertility increases because
– availability of weaning foods
– child labor utilized in farming economies
• child rearing did not require as much investment since
they could be put to work earlier in life
– reduced strain on women carrying children
• more difficult to be mobile mother
– increased mortality
30 fold population increase over 4000 years
Agriculture
hierarchies emerged as
larger and denser
societies replaced
smaller societies in prehistory
– Knauft graph
– internal stratification
within individual societies
– inequality of power &
exchange between
societies
– began 5000 years ago
DIVISIONS
ruler / ruled
rich / poor
literate / illiterate
townspeople / peasants
Knauft graph
Agriculture
infectious diseases increase
– TB a disease of crowded urban poor and ghettoes and
reservations
– bubonic plague
– influenza and cholera with international military operations
– AIDS
contemporary forager-hunters display low rates of
• infantile and other diarrhea, anemia
• epidemic diseases
• only have chronic diseases and some zoonotic and soil
borne diseases which don’t depend on people for survival
and transmission
Health Declined with agriculture
“Agriculture has long been regarded as an
improvement in the human condition: Once
Homo sapiens made the transition from
foraging to farming in the Neolithic, health and
nutrition improved, longevity increased, and
work load declined. Recent study of
archaeological human remains worldwide by
biological anthropologists has shown this
characterization of the shift from hunting and
gathering to agriculture to be incorrect.
Contrary to earlier models, the adoption of
agriculture involved an overall decline in
oral and general health.” (Larsen, C. S. (1995). "Biological
changes in human populations with agriculture." Annual Review of Anthropology)
80
70
60
Japan
Life Expectancy Trends: Paleolithic On
USA
Russia
50
40
30
20
Paleolithic
Sub-Saha ran
Afr ica
Rome
Present (1990) (1900) 1000 10000 100,000
Ye a r s b e f o r e p r e s e n t ( l o g s c a l e )
Population Health Measures in History
life expectancy estimates lie in range of 20
to 50 years until the last century
• 25 years is estimate for
– Europe in 18th & early 19th century
– urban Europe well into the 19th century
– Japan had higher life expectancy than W.
Europe 19th century
• Italy, Spain, Hungary it was below 30 for most of 19th
century
• US no data on life expectancy before 1900 but suspect
higher than Europe (less hierarchy then)
– better than India prior to 1920
Hundreds of years ago:
Life Expectancy increased
after childhood
Leigh & Jencks 2007
GLOBAL HEALTH Theories:
– Living standards improvements (Preston)
– Sanitation
– technical improvements preventing early death?
– Nutrition (Fogel, McKeown (medical treatment
played minor role)
– Social factors (Caldwell in 1980s), female education
– Psychosocial factors
– Qualitative changes
– Biological changes
– Treatment of early life
– Culture?
Leigh & Jencks 2007
Europe after 1900
psychosocial changes
Better standards of treating children
childhood
"The history of childhood is a
nightmare from which we
have only recently begun to
awaken. The further back
in history one goes the
lower the level of child care,
and the more likely children
are to be killed, abandoned,
beaten, terrorized and
sexually abused."
DeMause The History of
Childhood 1974
Europe after 1900
psychosocial changes
Better standards of treating children
Societies less repressive
– Fewer public hangings
– Less cruelty to animals
– Softening quality of social relations
– Decreasing reliance on threat or fear as basis of
social order
– Growth of democracy, equality before law
Development of welfare state
Murray and Chen 1993:
theory
3 inter-dependent factors at work:
1. Level and distribution of national
income
2. Effectiveness of public policies
3. Efficiency and effectiveness of public
policies toward mortality control
Terminology
Most of the world (them)
Third world
Less developed countries
Less industrialized countries
Majority countries
Majority world
Former colonies
Exploited countries
Underdeveloped countries
Developing countries
South
Us
First world
Developed countries
Industrialized countries
Minority countries
Minority world
Colonizing countries
Imperialist countries
Overdeveloped countries
North
Changes after 1950
development
"Late development" Ron Dore
– Poorer, less developed nations learn from our
mistakes
"development" a charged valued driven word
– Different meaning than "child development"
• or "plant development" which are natural processes
Nothing natural about 'development' in reference to
natural process for a nation or society
QUIZ
one country has TWICE the child
mortality of the other
Sri Lanka or Turkey?
Poland or South Korea?
Malaysia or Russia?
US or Sweden?
Pakistan or Vietnam?
Thailand or South Africa?
QUIZ
one country has TWICE the child
mortality of the other
Sri Lanka or Turkey?
Poland or South Korea?
Malaysia or Russia?
US or Sweden?
Pakistan or Vietnam?
Thailand or South Africa?
Making Transition Work for Everyone: Poverty and Inequality in Europe and Central
Asia, World Bank 2001
Health Olympics 2004 UNDP HDR 2006
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
Japan
Hong Kong
Iceland
Switzerland
Australia
Sweden
Canada
Italy
Israel
Spain
Norway
France
New Zealand
Austria
Belgium
Germany
Singapore
Finland
Cyprus
Luxembourg
Malta
Netherlands
United Kingdom
Greece
Costa Rica
United Arab Emirates
Chile
Ireland
Cuba
United States
Portugal
Denmark
Korea,
Kuwait
Slovenia
Brunei
Czech Republic
Uruguay
Dominica
Barbados
Mexico
Croatia
Panama
Argentina
Poland
82.2
81.8
80.9
80.7
80.5
80.3
80.2
80.2
80
79.7
79.6
79.6
79.3
79.2
79.1
78.9
78.9
78.7
78.7
78.6
78.6
78.5
78.5
78.3
78.3
78.3
78.1
77.9
77.6
77.5
77.5
77.3
77.3
77.1
76.6
76.6
75.7
75.6
75.6
75.3
75.3
75.2
75
74.6
74.6
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
Bahrain
Ecuador
Slovakia
Oman
Bosnia & Herzegovina
Sri Lanka
Antigua & Barbuda
Macedonia,
Albania
Libyan Arab Jamahiriya
Syria
Tunisia
Malaysia
Hungary
Qatar
Venezuela,
Seychelles
Palestine
Colombia
Saint Lucia
Lithuania
Bulgaria
Tonga
Mauritius
Lebanon
Saudi Arabia
China
Latvia
Belize
Estonia
Armenia
Jordan
Romania
Algeria
Saint Vincent & Grenadines
Paraguay
El Salvador
Brazil
Viet
Philippines
Iran,
Jamaica
Cape Verde
Georgia
Samoa (Western)
74.5
74.5
74.3
74.3
74.3
74.3
73.9
73.9
73.9
73.8
73.6
73.5
73.4
73
73
73
72.7
72.7
72.6
72.6
72.5
72.4
72.4
72.4
72.2
72
71.9
71.8
71.8
71.6
71.6
71.6
71.5
71.4
71.3
71.2
71.1
70.8
70.8
70.7
70.7
70.7
70.7
70.6
70.5
GLOBAL
HEALTH
2004/06
Gap 51
years
1990/93
Gap 37
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
Thailand
Bahamas
Peru
Egypt
Saint Kitss and Nevis
Nicaragua
Morocco
Trinidad Tobago
Suriname
Turkey
Vanuatu
Belarus
Moldova,
Honduras
Fiji
Guatemala
Dominican Republic
Indonesia
Kyrgyzstan
Maldives
Azerbaijan
Uzbekistan
Ukraine
Grenada
Russian Federation
Mongolia
Bolivia
Tajikistan
Comoros
Guyana
India
Kazakhstan
Pakistan
Bhutan
Bangladesh
São Tomé & Principe
Solomon Islands
Turkmenistan
Nepal
Yemen
Myanmar
Ghana
Cambodia
Sudan
Gambia
70.3
70.2
70.2
70.2
70
70
70
69.8
69.3
68.9
68.9
68.2
68.1
68.1
68
67.6
67.5
67.2
67.1
67
67
66.6
66.1
65.3
65.2
64.5
64.4
63.7
63.7
63.6
63.6
63.4
63.4
63.4
63.3
63.2
62.6
62.5
62.1
61.1
60.5
57
56.5
56.5
56.1
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
Timor-Leste
Senegal
Papua New Guinea
Madagascar
Lao
Togo
Eritrea
Benin
Gabon
Guinea
Mauritania
Djibouti
Congo
Haiti
Uganda
Mali
Burkina Faso
Ethiopia
Kenya
Namibia
South Africa
Tanzania,
Côte d'Ivoire
Cameroon
Guinea-Bissau
Niger
Rwanda
Burundi
Chad
Congo (DR)
Nigeria
Equatorial Guinea
Mozambique
Angola
Sierra Leone
Malawi
Central African Republic
Zambia
Zimbabwe
Lesotho
Botswana
Swaziland
56
56
55.7
55.6
55.1
54.5
54.3
54.3
54
53.9
53.1
52.9
52.3
52
48.4
48.1
47.9
47.8
47.5
47.2
47
45.9
45.9
45.7
44.8
44.6
44.2
44
43.7
43.5
43.4
42.8
41.6
41
41
39.8
39.1
37.7
36.6
35.2
34.9
31.3
Health Olympics 2004 UNDP HDR 2006
Japan 82.2
Hong Kong
Switzerland
Australia
Sweden
Canada
Italy
Israel
Spain
Norway
France
New Zealand
Austria
Belgium
Germany
Singapore
Finland
Netherlands
United Kingdom
Greece
Costa Rica
United Arab Emirates
Chile
Ireland
Cuba
United States
Portugal 77.5
Denmark
Korea,
Czech Republic
Uruguay
Mexico
Croatia
Panama
Argentina
Poland
Ecuador
Slovakia
Bosnia Herzegovina
Sri Lanka 74.3
Macedonia,
Albania
Libya
Syria
Tunisia
Malaysia
Hungary
Venezuela 73
Palestine
Colombia
Lithuania
Bulgaria
Lebanon
Saudi Arabia
China 71.9
Armenia
Jordan
Romania
Algeria
Paraguay
El Salvador
Brazil
Viet Nam 70.8
Philippines
Iran,
Georgia
Thailand 70.3
Peru
Egypt
Nicaragua
Morocco
Turkey
Belarus
Moldova,
Honduras
Guatemala
Dominican Republic
Indonesia
Kyrgyzstan
Azerbaijan
Uzbekistan
Ukraine
Russian Federation
Bolivia
Tajikistan 63.7
India 63.6
Kazakhstan
Pakistan
Bangladesh
Turkmenistan
914 million
690 million
1929 million
789 million
1689 million
567 million
2.5 YEARS
6.7 YEARS
15 YEARS
17 YEARS
LIFE EXPECTANCY RANGE
5.7 YEARS
4.5 YEARS
Nepal
Yemen
Myanmar
Ghana
Cambodia
Sudan
Senegal
PNG
Madagascar
Lao
Togo
Eritrea
Benin
Guinea
Mauritania
Djibouti
Congo
Haiti
Uganda
Mali 48
Burkina Faso
Ethiopia
Kenya
South Africa 47
Tanzania,
Côte d'Ivoire
Cameroon
Niger
Rwanda
Burundi
Chad
Congo (DR)
Nigeria
Eq Guinea
Mozambique
Angola
Sierra Leone
Malawi
CAR
Zambia
Zimbabwe
Swaziland
Factors influencing
global health
today
National Health Determinants
Where countries were in the health olympics
starting blocks
National Health Determinants
Where countries were in the health olympics
starting blocks
Colonial history 3 types:
1 few Europeans settled (PEASANT COLONIES)
– societies were peasant colonies with Europeans as
administrators or tax collectors or exploiters
• plantations dominated economy in some places
– Europeans didn't stay in power after independence
– Outcomes depended on how much Europeans
helped local elites to plunder
– India, Nigeria, Sri Lanka
National Health Determinants
Where countries were in the health olympics starting blocks
Colonial history:
2 Europeans settled as a minority (SETTLER
COLONIES)
– Tended to expropriate land and resources
– Used indigenous peoples labor, imported slaves
• Plantations, mining in Americas
• Locals often not allowed to own land
– After independence Europeans remained in power
• Colonial system prevailed with elite exploitation
National Health Determinants
Where countries were in the health olympics starting blocks
Colonial history:
3 Europeans settled as a majority (NEW
EUROPE COLONIES)
– Wiped out local peoples
– Adopted systems similar to homeland Europe
– Where there was more slavery, there was a greater
hierarchy and worse health outcomes
Health Determinants of nations
Where countries were in the health olympics starting blocks
How well they provided basic needs (food)
How much they support early life
How much they support ALL (social welfare systems)
Sense of community, social capital
Culture, values, ethos
Political systems: especially redistributive policies
–
"educated, capable, and demanding public" (Caldwell 1986)
Economic growth (up to ~1850 ↑living standards), then whether
rapid & shared or not, if not shared, can worsen health
Hierarchy details: economic, social
Access to health care
Public health programs
Health Determinants of nations
Where countries were in the health olympics starting blocks
How well they provided basic needs (food)
How much they support early life
How much they support ALL (social welfare systems)
Sense of community, social capital
Culture, values, ethos
Political systems: especially redistributive policies
–
"educated, capable, and demanding public"
Economic growth (up to ~1850 ↑living standards), then whether
rapid & shared or not, if not shared, can worsen health
Hierarchy details: economic, social
Access to health care, Public health programs
Health - Growth or GNP/capita
Up to about $5000/capita GNP, further increases
are associated with better population health
After about $5000/capita GNP, there is little gain
associated with further economic growth
Deaton 2003
Highest Life Expectancy
And disability free years
Life expectancy disparity
is 16 years
HAPPIER
Diener et. al. 2004
Lowest Life Expectancy
And disability free years
BIGGER ECONOMY
Health & Economic Transition
Taiwan in 1970s, health related to per capita
income
Taiwan in 1990s, health related to income gap
Determinants of Health in Poor
Countries?
Basic needs satisfied first
Then hierarchy predominates
– how to measure hierarchy?
measuring hierarchy in poor
countries
Consumption
– Commodities owned?
•
•
•
•
Radios
Television
Automobiles
Computers
Distribution of education
Land ownership
DOES LEVEL OF GNP MATTER?
Houweling et. al. 2005
(Africa): Benin, Burkina Faso,
Cameroon, Central African Republic,
Chad, Comores, Cote d’Ivoire, Ghana,
Kenya, Madagascar, Malawi, Mali,
Mozambique, Namibia, Niger, Nigeria,
Senegal, Tanzania, Togo, Uganda,
Zambia, Zimbabwe;
(Asia): Bangladesh, India, Indonesia,
Nepal, Pakistan, Philippines, Vietnam;
(Latin America): Bolivia, Brazil,
Colombia,
Dominican Republic, Guatemala,
Haiti,
Nicaragua, Paraguay, Peru;
(Other): Kazakhstan, Kyrgyz Republic,
Morocco, Turkey, Uzbekistan.
Impact of Public Health Spending?
Some health effect on poor
– Mostly on those living on less than $1/day
– (studies suggest poorest quintile in Africa received
significantly less than 20% of subsidized health
care than richest quintile) and India as discussed
– Richest 20% received most subsidy from public
health spending except in S. Africa where they use
private care
IMR & Under Five Mortality gradient
with consumption
Other Important factors affecting health
Militarization
– # of military personnel per
1000 men has -0.28
correlation with IMR
– Arms imports also
negatively associated with
IMR
Political rights
-0.26 correlation with IMR
Democracy and political will
Ethnolinguistic fractionalization
– Ethnic child mortality
differences closely linked
with economic inequality
(not rural/urban,
education or nutritional
status)
– Similar to findings in US
with Black/White
– (Racism)
Democracy and political will
30% lower IMR in liberal political regimes and
democracies compared to least free
Kennedy et. al. 1997
Ethnolinguistic Fractionalization (Racism: Difference plus power)
McCord et. al. 1991 NEJM
Moi
Kibaki
Country categorizations for
Population health
Rich countries
– Hierarchy matters most
Very poor countries
– Basic needs (food, water, shelter) matter most
In between countries
– Elements of both for different sub-populations