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 20-75spent most of the time in leisure pursuits in small,

close-knit groups called bandsvery little hierarchy, vigilant sharingvery 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 PresentForager-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 hunter-gatherer. 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 family-

level 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 SocietiesEmerged 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 SocietiesAnthropological 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)

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)

Agricultural Societies

Agriculturevillages: 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 pre-history

– 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

Agricultureinfectious 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

“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)

Health Declined with agriculture

Sub-SaharanAfrica

Russia

Present (1990) (1900) 1000 10000 100,000

Y e a r s b e f o r e p r e s e n t ( l o g s c a l e )

Japan

USA

Rome

Paleolithic

20

30

50

60

70

80

40

Life Expectancy Trends: Paleolithic On

Population Health Measures in Historylife 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 1900psychosocial 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 1900psychosocial 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

UsFirst worldDeveloped countriesIndustrialized countriesMinority countriesMinority worldColonizing countriesImperialist countriesOverdeveloped countriesNorth

Changes after 1950development

"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

QUIZone country has TWICE the child

mortality of the otherSri Lanka or Turkey?

Poland or South Korea?

Malaysia or Russia?

US or Sweden?

Pakistan or Vietnam?

Thailand or South Africa?

QUIZone country has TWICE the child

mortality of the otherSri 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 20061 Japan 82.2 46 Bahrain 74.5 91 Thailand 70.3 136 Timor-Leste 562 Hong Kong 81.8 47 Ecuador 74.5 92 Bahamas 70.2 137 Senegal 563 Iceland 80.9 48 Slovakia 74.3 93 Peru 70.2 138 Papua New Guinea 55.74 Switzerland 80.7 49 Oman 74.3 94 Egypt 70.2 139 Madagascar 55.65 Australia 80.5 50 Bosnia & Herzegovina 74.3 95 Saint Kitss and Nevis 70 140 Lao 55.16 Sweden 80.3 51 Sri Lanka 74.3 96 Nicaragua 70 141 Togo 54.57 Canada 80.2 52 Antigua & Barbuda 73.9 97 Morocco 70 142 Eritrea 54.38 Italy 80.2 53 Macedonia, 73.9 98 Trinidad Tobago 69.8 143 Benin 54.39 Israel 80 54 Albania 73.9 99 Suriname 69.3 144 Gabon 54

10 Spain 79.7 55 Libyan Arab Jamahiriya 73.8 100 Turkey 68.9 145 Guinea 53.911 Norway 79.6 56 Syria 73.6 101 Vanuatu 68.9 146 Mauritania 53.112 France 79.6 57 Tunisia 73.5 102 Belarus 68.2 147 Djibouti 52.913 New Zealand 79.3 58 Malaysia 73.4 103 Moldova, 68.1 148 Congo 52.314 Austria 79.2 59 Hungary 73 104 Honduras 68.1 149 Haiti 5215 Belgium 79.1 60 Qatar 73 105 Fiji 68 150 Uganda 48.416 Germany 78.9 61 Venezuela, 73 106 Guatemala 67.6 151 Mali 48.117 Singapore 78.9 62 Seychelles 72.7 107 Dominican Republic 67.5 152 Burkina Faso 47.918 Finland 78.7 63 Palestine 72.7 108 Indonesia 67.2 153 Ethiopia 47.819 Cyprus 78.7 64 Colombia 72.6 109 Kyrgyzstan 67.1 154 Kenya 47.520 Luxembourg 78.6 65 Saint Lucia 72.6 110 Maldives 67 155 Namibia 47.221 Malta 78.6 66 Lithuania 72.5 111 Azerbaijan 67 156 South Africa 4722 Netherlands 78.5 67 Bulgaria 72.4 112 Uzbekistan 66.6 157 Tanzania, 45.923 United Kingdom 78.5 68 Tonga 72.4 113 Ukraine 66.1 158 Côte d'Ivoire 45.924 Greece 78.3 69 Mauritius 72.4 114 Grenada 65.3 159 Cameroon 45.725 Costa Rica 78.3 70 Lebanon 72.2 115 Russian Federation 65.2 160 Guinea-Bissau 44.826 United Arab Emirates 78.3 71 Saudi Arabia 72 116 Mongolia 64.5 161 Niger 44.627 Chile 78.1 72 China 71.9 117 Bolivia 64.4 162 Rwanda 44.228 Ireland 77.9 73 Latvia 71.8 118 Tajikistan 63.7 163 Burundi 4429 Cuba 77.6 74 Belize 71.8 119 Comoros 63.7 164 Chad 43.730 United States 77.5 75 Estonia 71.6 120 Guyana 63.6 165 Congo (DR) 43.531 Portugal 77.5 76 Armenia 71.6 121 India 63.6 166 Nigeria 43.432 Denmark 77.3 77 Jordan 71.6 122 Kazakhstan 63.4 167 Equatorial Guinea 42.833 Korea, 77.3 78 Romania 71.5 123 Pakistan 63.4 168 Mozambique 41.634 Kuwait 77.1 79 Algeria 71.4 124 Bhutan 63.4 169 Angola 4135 Slovenia 76.6 80 Saint Vincent & Grenadines 71.3 125 Bangladesh 63.3 170 Sierra Leone 4136 Brunei 76.6 81 Paraguay 71.2 126 São Tomé & Principe 63.2 171 Malawi 39.837 Czech Republic 75.7 82 El Salvador 71.1 127 Solomon Islands 62.6 172 Central African Republic 39.138 Uruguay 75.6 83 Brazil 70.8 128 Turkmenistan 62.5 173 Zambia 37.739 Dominica 75.6 84 Viet 70.8 129 Nepal 62.1 174 Zimbabwe 36.640 Barbados 75.3 85 Philippines 70.7 130 Yemen 61.1 175 Lesotho 35.241 Mexico 75.3 86 Iran, 70.7 131 Myanmar 60.5 176 Botswana 34.942 Croatia 75.2 87 Jamaica 70.7 132 Ghana 57 177 Swaziland 31.343 Panama 75 88 Cape Verde 70.7 133 Cambodia 56.544 Argentina 74.6 89 Georgia 70.6 134 Sudan 56.545 Poland 74.6 90 Samoa (Western) 70.5 135 Gambia 56.1

2004/06Gap 51years

1990/93Gap 37

GLOBALHEALTH

Health Olympics 2004 UNDP HDR 2006Japan 82.2 Portugal 77.5 Venezuela 73 Thailand 70.3 Tajikistan 63.7 Mali 48Hong Kong Denmark Palestine Peru India 63.6 Burkina FasoSwitzerland Korea, Colombia Egypt Kazakhstan EthiopiaAustralia Czech Republic Lithuania Nicaragua Pakistan KenyaSweden Uruguay Bulgaria Morocco Bangladesh South Africa 47Canada Mexico Lebanon Turkey Turkmenistan Tanzania,

Italy Croatia Saudi Arabia Belarus Nepal Côte d'IvoireIsrael Panama China 71.9 Moldova, Yemen CameroonSpain Argentina Armenia Honduras Myanmar NigerNorway Poland Jordan Guatemala Ghana RwandaFrance Ecuador Romania Dominican Republic Cambodia BurundiNew Zealand Slovakia Algeria Indonesia Sudan ChadAustria Bosnia Herzegovina Paraguay Kyrgyzstan Senegal Congo (DR)Belgium Sri Lanka 74.3 El Salvador Azerbaijan PNG NigeriaGermany Macedonia, Brazil Uzbekistan Madagascar Eq GuineaSingapore Albania Viet Nam 70.8 Ukraine Lao MozambiqueFinland Libya Philippines Russian Federation Togo AngolaNetherlands Syria Iran, Bolivia Eritrea Sierra LeoneUnited Kingdom Tunisia Georgia Benin MalawiGreece Malaysia Guinea CARCosta Rica Hungary Mauritania ZambiaUnited Arab Emirates Djibouti ZimbabweChile Congo SwazilandIreland HaitiCuba UgandaUnited States

914 million 690 million 1929 million 789 million 1689 million 567 million

LIFE EXPECTANCY RANGE5.7 YEARS 4.5 YEARS 2.5 YEARS 6.7 YEARS 15 YEARS 17 YEARS

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 DeterminantsWhere 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 DeterminantsWhere 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 nationsWhere countries were in the health olympics starting blocks

How well they provided basic needs (food)How much they support early lifeHow much they support ALL (social welfare systems)Sense of community, social capitalCulture, 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 carePublic health programs

Health Determinants of nationsWhere countries were in the health olympics starting blocks

How well they provided basic needs (food)How much they support early lifeHow much they support ALL (social welfare systems)Sense of community, social capitalCulture, 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 ExpectancyAnd disability free years

Lowest Life ExpectancyAnd disability free years

Life expectancy disparityis 16 years

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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

Ethnolinguistic Fractionalization (Racism: Difference plus power)

Kennedy et. al. 1997

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