Cultural and Social Factors Influencing Mortality Levels in Developing Countries

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Cultural and Social Factors Influencing Mortality Levels in Developing Countries

Author(s): John C. Caldwell

Source: Annals of the American Academy of Political and Social Science, Vol. 510, World

Population: Approaching the Year 2000, (Jul., 1990), pp. 44-59

Published by: Sage Publications, Inc. in association with the American Academy of Political

and Social Science

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ANNALS, AAPSS,510, July 1990

Culturaland Social Factors

InfluencingMortalityLevels in

DevelopingCountries

ByJOHNC. CALDWELL

ABSTRACT:ecentanalysesof ThirdWorlddata,bothat the level of national

or otherlarge aggregatesandat that of individualsstudied n sample surveys,have revealedthe surprising act thatsocial characteristics,uch as the level of

schooling or fertilitycontrol,or culturalcharacteristics,uch as ethnic group,are usually more influentialin determiningmortality evels than is access tomedicalservices, income,or nutritionalevels. Evidence from theUnitedStates

at thebeginningof thecenturysuggeststhat thiswas not the case earlier n the

West.Thisarticleexamines theevidence,showswhy developingcountriesare

currentlynan unusual ituation,andpresentsanthropologicalvidence on how

cultural, ocial, andbehavioral actorsachievetheir mpact.An attempts madeto begin the constructionof a moregeneral theoryof mortality ransition.

John Caldwell receivedhis Ph.D. degreeindemographyat theAustralianNationalUniversity,Canberra.He and his wife,Pat Caldwell,haveresearchedpopulation changevia anthropologicalanddemographic ield-research echniquesn Thailand,Malaysia,sub-SaharanAfrica,India,andSri Lanka.From1970 to 1988he was headof theAustralianNationalUniversity'sDepartmentofDemographyand now isdirectorof its Health TransitionCentre.He is authorof Theoryof FertilityDecline; and coauthorof The Causes of DemographicChange:ExperimentalResearch n SouthIndia.

44



MORTALITYLEVELSIN DEVELOPINGCOUNTRIES

OVER the last 100 years,the historyof

mortality n the West has given all

the appearancesof supportinga common-sense and economic-deterministnterpre-tationof healthchange.During hatperiod,life expectancy in the most developedcountries increasedby more than 50 per-cent, from under 50 years to around75

years.Nothinglike this hadhappenedbe-fore inhumanhistory.But noone wasverysurprised,becauseotherchangesof funda-

mental mportancehadalsooccurred:withthe full floweringof the IndustrialRevolu-

tion, real incomes in the most economi-

cally advanced countries had multipliedalmost tenfold over that period. This al-

lowed people to be better fed and clad,

permitted the construction of improved

hospitalsthat the populacecould increas-

ingly afford to use, and providedthe re-

sources to treatdrinkingwaterandsewage.At thesametime,theinterrelated cientificrevolutionfirst madesafermedicalproce-dures possible and ultimately producedsulfa drugs,antibiotics,new vaccines,and

powerfulinsecticides.

Material improvement and scientific

advance seemed to have been the main

engines drivingdown mortality,an inter-

pretationthat this article will arguewasnot, for theWest,farwrong.Furthermore,for most of this period, the interpretationwas largely confined to the West, partlybecause most analysts lived there but

largelybecausethere was little in the wayof healthstatisticselsewhere.Thisfact wasto cloud our interpretation f the forcesbehind heglobalmortality ransitionwhen

itbegantogathermomentum nthepresentcentury.

Certainly, t was known thatthese ad-vanceswere notequallyshared.As earlyas1852WilliamFarrhaddemonstratedmajor

mortalitydifferentials nEnglandby socio-

economicclass,'butthesewereassumed o

reflect real differences in the means tobring minimum comfort and to pay fortreatment and little else. Not everyoneagreedthatindividualbehaviorplayedno

significantrole in determining helevel of

mortality,as was shown by the aims andactivitiesof the InfantWelfareMovementin English-speaking countries before

WorldWarI or by the MaternalandChild

Welfare Movements of the 1920s and1930s.2A revisionistapproach o the his-

tory of medicine has been developed inrecentdecadesby ThomasMcKeownand

colleagues,3 but the thrust of this workhas been to emphasizethe impactof eco-nomic changeat the expense of scientificmedicine.

NEWEVIDENCEFROMDEVELOPINGCOUNTRIES

A major hiftin ourinterpretationf the

mortalityransition asbeenmadepossibleby a change of focus to the developmentproblemsof the ThirdWorld,where life

expectancy in sub-SaharanAfrica is stillbelow50 yearsand nSouthAsiabelow 55

years.These are

populations argelylack-

1. William Farr,Vital Statistics: A MemorialVolume fSelectionsfromtheReportsandWritings fWilliamFarr(Metuchen,NJ:ScarecrowPress,1975).

2. EllenRoss,"Mothers nd theState nBritain,1904-1914" Paperdeliveredat theConferenceon the

HistoricalContext and Consequencesof Declining

Fertility n Europe,CambridgeMeeting,July 1989);Philippa Mein Smith, "InfantSurvival, the Infant

Welfare Movement and Mothers'Behaviour,Aus-

tralia with Referenceto New Zealand, 1900-1945"(Ph.D. thesis, AustralianNational University,Can-

berra,1989).3. Thomas McKeown, The Role of Medicine:

Dream,MirageorNemesis (London:NuffieldHospi-talsTrust,1967).

45



THEANNALS OF THE AMERICANACADEMY

ing adequate death registrationsystemsand medical identificationof the cause of

death,so adequatedatabankson mortalityand social and economic conditionshave

been amassedby the United Nations and

the WorldBankonly in recentyears.This evidence shows that levels of in-

come andhealth servicesareweakpredic-torsof mortality evels and that social de-

terminantsapparentlyplay a majorrole in

determiningmortality.Thisarticlesumma-

rizes thatevidence, attempts o employ itto explain global mortality ransition,and

analyzesthe available nformation n how

social factors affect death rates.

It has become increasinglyclear that

ThirdWorld nationalmortality evels ex-

hibit a very differentpatternfrom what

their income levels would imply. Some

poor developing countries have largely

escaped the Malthusianshackles. A 1985Rockefeller Foundation Conference4se-

lected for investigatory study four Third

Worldsocieties thathadachievedlow lev-

els of mortality"at low cost": certainly,when comparedwith developedcountries

with similar mortalitylevels, at absolute

low cost, but not always at relativelylow

cost if the measure is the proportionof

national ncome spenton health andsocialservices likelyto assistthemaintenance f

health. The societies chosen-Sri Lanka;Kerala State, in southwest India;China;andCostaRica-all had life expectanciesin the 66- to 70-yearrange.In the case ofthe firstthreesocieties, thiswas at least 15

yearshigherthantheaverageforcountrieswith similarincomes, about3 yearslower

than Eastern Europe, and only 7 yearsbelowWesternEuropeandNorthAmerica.This level of mortalityhadbeen achieved

4. Scott B. Halstead,Julia A. Walsh,and Ken-nethS. Warren,GoodHealthat LowCost(New York:

RockefellerFoundation,1985).

by these three societies with per capitaincomes in the $300-400 range, or one-

fortieththat of WesternEuropeand one-fiftieth of North America.5 Considerable

attentionwas paid to the nature of theirhealth and social services.

Partof theexplanation or the high life

expectancies probablylies in the social-

service net that Sri Lanka, China, and

Costa Rica provide. It should be noted,however that Sri Lankaspends only 1.2

percent of its gross nationalproductonhealth, slightly above the averagefor its

income level, comparedwith 3.7 percentforWestern ndustrializedountries,which

spend, in absoluteterms,about140 times

as muchper person.6 ntermsof the num-

berof inhabitants er physician,SriLanka,with 7500 personsperdoctor,or 15 times

as many as in the West, is typical of its

income level;7Keralaprobablypresentsasimilarpicture,although he identification

for statisticalpurposesof doctors in both

India and China includes many personswhom othercountrieswould exclude andso makes comparisons impossible. Theconclusion is inescapablethatneitherin-

come northe levels of healthservicesandinterventionsare the primaryexplanation

for the remarkable ealthachievementsofthese societies.

The new data banksprovidedvaluableclues. Multivariateanalysis allowed thelevel of a rangeof socioeconomicfactorsand healthinputsin developingcountriesto be related to mortality levels. Flegg

5. Cf. WorldBank,WorldDevelopmentReport,

1988 (New York:OxfordUniversityPress,1988), pp.222-23, tab. 1.

6. Ibid.,pp.266-67, tab.23. Therearenofiguresfor Kerala, which probablyspends less, or China,while Costa Rica spends a proportionof the grossnationalproduct n the rangeof the proportion pentby the industrialized ountries.

7. Ibid.,pp.278-79, tab.29.

46



MORTALITYLEVELS IN DEVELOPINGCOUNTRIES

showed that the level of literacywas the

best indicatorof low infant mortality,al-

though the degree of equality in incomeand the level of medical care also played

importantroles.8 Caldwell demonstrated

that ow nationalmortalitywas mosthighlycorrelatedwith the proportionof femalesin school a generationearlier,and that the

levels of familyplanningpracticeandmale

school attendancewere also importantn-

dicators of low mortality.9Lowercorrela-

tions were found with the ratio of doctorsto populationandnutritionalevels, andastill lower correlationwith income levels.

Recently,Rogers and Wofford have con-

firmed the prime role of literacy and the

proportionof the populationworkingout-

side agricultureand,of lesser importance,the safety of the water supply.'?Health

inputs,as measuredby the ratio of physi-

cians to population,showed a lower levelof correlation, while nutrition was notfoundto be significant.The importanceof

schooling a generationearlierlies in the

fact that it determinesthe current evel of

parental ducation,especially importantn

the case of mothers.The markeddifferen-tial in thesurvivalof childrenaccording othe level of mother'seducation had been

noted nGhana nthe1960sbyGaisie" andin a rangeof LatinAmericancountries n

8. A. T. Flegg, "Inequality f Income,IlliteracyandMedical Careas Determinants f InfantMortalityin UnderdevelopedCountries,"PopulationStudies,

36(3):441-58 (Nov. 1982).9. John C. Caldwell,"Routes o Low Mortality

in PoorCountries," opulationandDevelopmentRe-

view, 12(2):179, tab. 3 (June 1986).

10. RichardG.RogersandSharonWofford,"LifeExpectancy n Less DevelopedCountries:Socioeco-nomic Development or Public Health?"Journal ofBiosocial Science, 21:245-52 (1989).

11. S. K.Gaisie,DynamicsofPopulationGrowthin Ghana, GhanaPopulationStudies no. 1 (Legon,Accra: University of Ghana, Demographic Unit,1969).

the 1970s by Behm.Y2 he importanceof

child survival for determining mortality

levels lies inthefactthat, n high-mortalitycountries,typicallyat least one-quarter fall birthsresultin deaths before 5 yearsof

age, andbecause of theage structure f the

population,halfof all deaths n thesocietyoccurto personsunder5 years.

Meanwhile, these macro observationswere being increasingly supported byindividual-leveldata collectedby national

and subnationalrepresentative urveys inthe ThirdWorld.A majoropportunitywas

presentedby theorganization f surveysof

good scientific quality in 45 developingcountries by the World Fertility Surveyprogramin the decade after 1975. Twodifferentanalysesl3argelysupported achotherin theirfindingthatparentaleduca-tion is the most important nfluence on

child survival, with mother's schoolingusually havingthegreater mpact.Income,evidenced by father'soccupation,is also

important.Child mortalitydeclines with

every additionalyear of mother'seduca-tion with no lower threshold,so that even

one or two years of schooling in a ruralschool has some impact.Furthermore,o-cial influences are of greater mportance,

as evidencedby widerdifferentialmortal-ity betweengroups,for childrenaged 1-4

yearsthanforinfants,presumablybecause

12. Hugo Behm, Final Reporton the Research

Project on Infant and ChildhoodMortality in theThird World Paris:Comit6international e cooper-ationdans les recherchesnationalesen demographie,

1983).13. John C. Caldwell and Peter F. McDonald,

"Influence f MaternalEducation n Infantand ChildMortality:Levels andCauses," nInternationalPop-ulation Conference,Manila, 1981, (Liege: Interna-tional Union for the Scientific Studyof Population,1981), 2:79-96;J. N. Hobcraft,J. W.McDonald,andS. O. Rutstein,"SocioeconomicFactors n InfantandChild Mortality: A Cross-National Comparison,"PopulationStudies,38(2):193-223 (July 1984).

47



THEANNALS OF THEAMERICANACADEMY

of theleveling effect on thelatterof nearlyuniversalbreast-feeding.

Mensch, Lentzner, and Preston ana-lyzed 15 surveysinAfrica, Asia, andLatin

America, only 6 of which were from theWorldFertility Survey program.They ex-

ploredthe impactof 12 groupsof social,

economic, andhealth-carevariables,bothuncontrolled and then controlledfor the

influence of theothervariables.Theycon-cluded that the majorinfluences on child

survivalwere mother'seducation,ethnic-ity, and, largely in urbanareas, father's

education.14Theextent towhichmaternal ducation

has beenidentifiedas amajor- or eventhe

major factor ndetermining hildmortal-

ity is astonishing,althougheven this find-

ing merely providesclues to the forces at

work ratherthan a simple answer.When

two socioeconomically similar areas inNigeria's Ekiti districtwere compared norder to discover the mortality mpactofdifferent levels of health services, it wasdiscoveredthat,even where therewas noaccess to modemhealthservices,mother's

schoolingwas animportant eterminant fchildsurvival.'5Research n southwestNi-

geria,especially in Ibadan, or the Chang-

ing African Family Project, showed thatthe importanceof maternaleducationre-mained after controllingfor the occupa-tions of bothmotherandfather, he urban-ruraldivision and the residential ocationwithin urbanareas,whetherthe marriage

14. United Nations, Socio-Economic Differen-tials in ChildMortality n Developing Countries,by

BarbaraMensch,HaroldLentzner,ndSamuelPreston,ST/ESA/SER.A/97NewYork:UnitedNations,1985).

15. I. O. Orubuloyeand JohnC. Caldwell,"The

Impact of Public Health Services on Mortality:A

Study of MortalityDifferentialsin a RuralArea of

Nigeria," Population Studies, 29(2):259-72 (July1975); Caldwell,"Routes o Low Mortality."

was monogamous or polygynous, and

whethertheparentspracticed amily plan-

ningor not.'6Mensch,Lentzner,andPres-tonconcluded:

When xaminedyitself,anadditionalearofmother'schooling educes hildmortality yanaverage crossour15countries f 6.8per-cent,with hemajorityfcountriesallingnthe

range f 5.0to9.0percent.Afterallother ari-ablesareenteredntotheestimationquation,theeffect s stilla reduction f 3.4 percentn

mortalityperyearof schooling.This latters the"direct" ffectof schoolingand s biaseddown-ward as an estimateof the "total" ffect by the

inclusion of variables whose value is partlydeterminedby mother'sschoolingitself.17

Maternal education and child survivalwere the focus of two papers,the first byClelandandvanGinneken'8 ndthesecond

by Clelandalone.The latterconcluded:

The mostimportanteatures f thematernaleducation-childhoodortalityssociationmaybe summarized hus:thereis no threshold; heassociation is found in all major developingregions; the linkage is strongerin childhood

than in infancy;only about half of the grossassociationcan be accountedfor by material

advantagesassociated with education;repro-ductive risk factorsplay a minorintermediaterole in the relationship; reaterequityof treat-mentbetweensons anddaughterss no partofthe explanation; the association betweenmother's education and child mortality is

slightly greater han for father'seducationand

mortality.19

16. John C. Caldwell,"Education s a Factor n

Mortality Decline: An Examination of NigerianData,"PopulationStudies,33(3):395-413 Nov.1979).

17. United Nations, Socio-Economic Differen-

tials, p. 287.18. JohnClelandandJeroenvanGinneken,"Ma-

ternalEducationand Child Survival in DevelopingCountries:The Search for Pathwaysof Influence,"SocialScienceandMedicine,27(12):1357-68(1988).

19. JohnCleland,"MaternalEducation ndChildSurvival: FurtherEvidence and Explanations," n

48




The pointthatmay not havebeen suffi-

ciently stressed is that education has two

separatebutmultiplicative mpacts,oneon

individualswhose behavior s changedrel-ative to theirsociety andone thatchangesthe whole society. An examinationof theWorldFertilitySurveysconcluded:

There s as close a correlation etweenchildsurvivalandgeneral evels of [female]edu-cation in a communityas thereis betweenchildsurvival ndmaternalducation. nedu-catedwoman

mayeelmore

deprivednacoun-

trywheremostotherwomenareeducatedhanin one wheretheyarenot; nevertheless, erchildren tanda muchgreater hanceof sur-vival.Ifwe take hese wo factorsogether,hecontrasts reenormous.nLatinAmerica,hedeathrateamong hechildren f uneducatedPeruvian omen s almost timesgreaterhan

amongVenezuelanwomenwithsevenyearsofeducation.nAsia, hemortalitymong hil-

drenof uneducatedepalesewomens almost15timesgreaterhan t is amonghoseof Ma-

laysianwomenwithseven or moreyearsof

schooling.20

One persistent, but underresearched,

finding is that there are major ethnic orcultural differentials in mortality, espe-cially child mortality,even in the same

countryandwiththe sameaccess to health

services- differences hatsurvivecontrol-ling for income and education.This hasbeen shown between Chinese andMalaysin Malaysia2'and between the different

What We Know about Health Transition:The Pro-

ceedings of an InternationalWorkshop,Canberra,

May 1989, ed. John C. Caldwell et al. (Canberra:Australian National University, Health Transition

Centre,1990).20. JohnC.

Caldwell,"MassEducationas a De-terminant of Mortality Decline" (CASID Lecture,

MichiganState University,25 Oct. 1988), reprintedin Selected Readings in Cultural,Social and Bhav-iouralDeterminantsof Health, ed. JohnC. CaldwellandGigi Santow(Canberra: ustralianNational Uni-

versity,HealthTransitionCentre,1989), pp.103-11.21. Julie DaVanzo,William P. Butz, and Jean-

Pierre Habicht, "How Biological and Behavioural

peoples of the West African savanna inruralMali.22Mensch,Lentzner,andPres-

tonexamined 60 ethnicgroups n 11coun-

triesof Africa,Asia,andLatinAmericaandalmost invariably ound significantethnicdifferentialsnchildsurvival neachcoun-

try,with the mortality evel in one groupsometimes being twice or more that ofanother.They noted thatChinesepopula-tionsinSoutheastAsiaarecharacterized yunusually ow mortality.23

Oneaspect

of theimpact

on child mor-

tality of different cultural attitudes and

practices s thatof preference orsonsover

daughters. This preference, where it is

found,almostcertainlykeepschildmortal-

ity higher han t mightotherwisebe inthatthe preferentialtreatmentis unlikely toforce male mortalitydown by as greatanadditional incrementas it unnecessarily

keeps female mortalityhigh. The WorldFertility Surveys provided for the first

time,by theuse of a life-historyapproach,substantially ccuratedataon childmortal-

ity by age and sex. This showed that inthe sensitive age rangeof 1-4 yearsthereis excess female over male mortalitythroughoutnearly all North Africa, theMiddle East, South Asia, and East Asia,

withgreaterdiversity nSoutheastAsiaandLatinAmerica,and little or no additional

danger for females only in sub-SaharanAfrica.24Data on differential ex mortalityfrom the IndianSampleRegistrationSur-

vey and the InternationalDiarrhoealDis-

Influences on Mortality n MalaysiaVaryduring he

FirstYearof Life,"PopulationStudies,37(3):381-402(Nov. 1983).

22. Allan G. Hill, ed., Population Health andNutritionin the Sahel: Issues in the Welfareof Se-lected WestAfrican Communities London: KeganPaulInternational, 985).

23. United Nations, Socio-Economic Differen-tials, pp. 77-111.

24. Shea O. Rutstein,"Infantand ChildMortal-

ity: Levels, TrendsandDemographicDifferentials,"Comparative tudies:Cross-National ummaries,no.

49



THEANNALS OF THE AMERICANACADEMY

eases Research Centre'sBangladeshpop-ulation laboratory n the Matlab district

demonstrate how culturally specific be-haviorcan affectmortality.Female mortal-

ityis not above thatof malesduring he first

yearof life, when breast-feedingprovides

equalnourishment ndprotectiveantibod-

ies; it is relativelyhigh in the 1- to 4-year

age range,when thatprotectionhas dwin-

dled but childrenare stillhighlydependenton others; t falls towardparitybetween 5

years and marriageas girls become morecapableof fending for themselves;and it

rises above that of males again during he

reproductive ears, argelybecause of highmaternalmortality in the poor obstetric

conditionsof much of SouthAsia. There-

after t falls below male levels.5

There is convincing evidence that the

achievementof a smallfamily,or even the

intentionof havingoneby employingbirthcontrol, s associatedwith declinesinchild

mortality.There is a correlationbetweennational evels of child mortalityandfam-

ily planning practice that compares onlywith that between maternaleducationand

ethnicity.26The Nigerian segment of the

ChangingAfricanFamily Project oundin

Ibadan ity child-mortalityevels thatwere

far lower among those women who hadachieved relatively small families than

amongthose who hadnot.27The One-per-

43, rev. ed. (London:WorldFertility Survey, Dec.

1984); Pat Caldwell and John C. Caldwell,"Where

There Is a NarrowerGapbetween Female and Male

Situations:Lessons from South Indiaand Sri Lanka"

(Paper delivered at the Social Science Research

CouncilWorkshop nGenderDifferentialsnMortal-

ity in SouthAsia, Dhaka,Bangladesh,Jan.1987).25. Caldwell and Caldwell, "Where There Is a

NarrowerGap."26. Caldwell,"Routes o Low Mortality," . 179,

tab. 3.

27. John C. Caldwell and Pat Caldwell, "TheAchieved Small Family: EarlyFertilityTransition n

anAfricanCity,"Studies nFamilyPlanning, 9(1):2-18, app.B (Jan.1978).

ThousandSurveyof Chinafoundextraor-

dinarily ow mortality mongonlychildren

whose parentshad completed the docu-mentationoptingfor thatstatus.28The in-

terrelationshere arecomplex and aredis-

cussed in the next section.I continued furtherwith the approach

adopted n the"GoodHealthat Low Cost"

conference.29A comparisonof the mortal-

ity andper capitaincome rankingsof the

99 ThirdWorldcountriesreportedully by

the WorldBankbecausetheirpopulationsexceed 1 million showed that,in termsof

their income, 11 did exceptionally well

withregard o health,being25 to62 places

higher in their health rankingsthan their

incomes would have predicted,while an-

other11didexceptionallybadly, alling25

to 70 placesbelowprediction.Armedwith

this informationand thatfromcorrelation

analysis, together with anthropological,

sociological,and historical nformation n

the societies thathad beenmost successfulin drivingdown mortalitywithin their in-

come constraints,hestudycameto a num-

ber of conclusions.Parental ducation s of

greatimportance, specially that of moth-

ers.So is the controlof fertilityor even the

attempt o controlit. Femaleautonomy

s

important,and its relative lack was the

mainreason that 9 of the 11 countries esssuccessful inconverting heir ncomesintolow mortalitywere found in the westernbranchof Islamstretching romSenegaltoIran. Grass-rootsradicalism,egalitarian-ism,anddemocracywereimportantnboth

creatinga successful populardemand for

health andeducational ervices andensur-ing that they worked. Neitherfemale au-

tonomy norradicalismhas as yet been as

successfully researched as education,

28. John C. Caldwell and K. Srinivasan,"NewData onNuptialityandFertility nChina,"PopulationandDevelopmentReview,10(1):71-79(Mar.1984).

29. Caldwell,"Routes o Low Mortality."

50




partlybecause there are no simple mea-

sures equivalent to years of schooling.30

Clearly,as is discussedin the next section,these characteristicsare interrelated.The

studywent far toward uggestingthatsoci-

eties arelargely prisonersof theircultures

and historiesand thatthe rootsof contem-

poraryhealthsuccesseslie farback nthose

histories. The exceptions were the suc-

cesses achievedbyCommunist evolutionsin Chinaand Vietnamand, ess certainly

because it earlierwas markedby some ofthe othercharacteristics-by Cuba.

Where thegreatestsuccesses over mor-

tality have been gained, this achievement

has been the productof an interactionbe-

tween certainculturaland social character-

istics on the one handand the easy acces-

sibilityof basic modem health services on

the other.In spite of the fact thatparental

educationandthe practiceof fertilitycon-trol correlate so much more highly with

mortality evels than do medicalinterven-tionsin thecontemporaryThirdWorld, heevidencestrongly suggeststhat alone theycannot make dramaticreductions n mor-

tality levels. They may, in fact, correlate

morehighlybecause health nvestmenthas

beenrunningaheadof social investment n

termsof the optimummix.Sri Lankahadexperiencedmassive so-

cial change by the 1920s.The 1921 census

hadfound 56 percentof males and21 per-cent of females to be literate,a level thatPakistanwas not to reach for anotherhalf

century.Yetlife expectancywas little over30 years.3'It was the provisionof health

30. John C. Caldwelland Pat Caldwell,"Wom-en's Position and Child Mortalityand Morbidity n

LDCs," n Conferenceon Women's ositionand De-

mographic Change in the Course of Development,Asker(Oslo) 1988 (Liege:InternationalUnionfor theScientific Studyof Population,1988), pp. 213-36.

31. Caldwell,"Routes o Low Mortality";T.Na-

darajah,"Trendsand Differentials in Mortality,"n

Population of Sri Lanka (Bangkok:Economic and

services,first n urbanareasandthen,from

1945 onward,rapidlyin ruralareas, that

allowed the subsequentdramaticfall indeathrates.Yetearlier hecountryhadbeen

highlysensitiveto the need to combatsick-

ness andpossessed one of the mostexten-

sive and developedsystems of traditional

medicine n the world. Traditionalmedical

systems may provide solace and reduce

pain and even symptoms in chronic or

other conditions,but the evidence seems

clear that modem medicine is needed todrive downmortality ates.

Francehad reduced ts fertility evel to

the equivalentof 3.5 birthsperwomanby1850, but its life expectancywas only 39

years.32Three societies that had experi-enced a great deal of social change-SriLanka,Kerala,and Costa Rica-enjoyed

periodsof intensive activity when health

serviceswerespreadmuch morewidely tothe ruralpopulationsand the urbanpoor

during the years 1946-53, 1956-71, and

1970-80,respectively;neach case mortal-

ity fell muchmorerapidly han nearlieror

lateryears.33 herearealso societieswherelack of specific types of social change,often female autonomyor female educa-

tion,means thatmajor nfusionsof modem

healthservices do not achieve theirantici-

pated impact. By 1980 Libya employedmore doctorspercapitathanJapanor Ire-

land and was reaching the levels of theUnitedKingdomandNewZealand,but ife

expectancytherewas 16 yearsshorterandthe infant mortalityrate seven times as

high.Thereis, then,some kind of

symbiosisbetween social changeand modernmedi-

Social Commission for Asia and the Pacific, 1976),

p. 148.

32. NathanKeyfitz, WorldPopulation:An Anal-

ysis of Vital Data (Chicago:Universityof ChicagoPress,1968).

33. Caldwell,"Routes o Low Mortality," . 181.

51



THEANNALS OFTHE AMERICANACADEMY

cine, the lattermeasuredmoreby itsacces-

sibility to a wide populationthan by its

level of technology.A comparisonof twosocioeconomically similarpopulationsin

Nigeria,one with access to a hospitaland

doctors and the other isolated from such

interventions, uggeststhatthegain in life

expectancy equivalent o the moreeasilymeasured hangesin childmortality- was

20 percentwhen the sole interventionwas

easy accessto adequatehealth acilities for

illiteratemothers,33 percentwhen it waseducationwithout healthfacilities, and87

percentwith both.34

Clelandand vanGinneken ummarized

datafroma wide rangeof countriesshow-

ing that the use of modem healthservicesincreased with duration of education.35

They believed that mostevidenceshowedthe interaction between education and

healthservices to be less spectacular hanthat found in Nigeria.36They reachedtheconclusion thataboutone-half of the verygreat differentialsfound across the ThirdWorld in child survival by educationofmother are probably explained by "eco-

nomic advantagesassociatedwith educa-tion (income, water and latrinefacilities,

clothing, housing quality, etc.)."37They

were morecautious abouthow the "pure"impact of mother's education was to bedivided between interactionwith modemmedicine and behavioral and care factorsthatpreventchildren frombecomingsickorhavingan accident n thefirstplace,but

theyemphasized hatbothwerelikelyto be

important. Income also interacts withhealth-serviceprovision,and this interac-

34. Ibid., p. 204; cf. Orubuloyeand Caldwell,

"Impactof PublicHealthServices."35. ClelandandvanGinneken,"MaternalEduca-

tion,"pp. 1361-62.

36. Ibid.,pp. 1362-63.37. Ibid.,p. 1360.

tion is especially strongwhenthere s little

attempt o providea free healthservice.

A rangeof researchers ttributemost ofthepureeffect of maternal ducation othebetteruse of modernhealthservices,buta

significantnumberalso attribute nimpor-tant role to family healthmanagementn-

dependent of curative services.38 In a

Nigerianvillage thatwas so farfrommod-em health services thatvery few childrenhad ever been takento doctors or nurses,

motherswith some schoolingexperiencedonly one-thirdthe child loss of motherswith no schooling. Only some of this canbe explained by greater use of modem

pharmaceuticals such as the malaria

suppressantsbroughtby a cyclist who ranan itinerantpharmacyservice.39 t mightalso be notedthat theskills in health man-

agement hatcanpreventchildren rombe-

comingsickordying nthe absenceof mod-em healthservices arethe same ones thatallow healthservices to be exploitedmore

successfully.Further onvincingevidenceof culturaland social differentials nchild

mortality n the pre-moder-medicine erahas been providedby researchamongso-cieties in ruralMaliwhere the modemerahas not yet begun.The substantialdiffer-

ence in child mortalitybetween adjacentculturalgroupswas explainedby different

styles of child care.40n contemporaryo-

cieties,somefamilies aremuchmoreproneto experiencesicknessand to lose childrenthanothers,as was shown fortyyearsago

38. For detailed references, see Caldwell and

Caldwell,"Women'sPosition,"pp. 222-23.

39. Orubuloyeand Caldwell,"Impactof PublicHealthServices,"p. 268.

40. KatherineHilderbrand t al., "Child Mortal-

ity and Careof Children n RuralMali"(Paperdeliv-eredat the National Institute or ResearchAdvance-ment and IUSSP Seminaron Social and BiologicalCorrelates f Mortality,Tokyo,24-27 Nov. 1984).

52




for Newcastle-upon-Tyne,England,41nd

recentlyin India.42

INTERPRETING HE EVIDENCE

TOFORMULATEA THEORYOF

HEALTHTRANSITION

The first proposition s that there have

alwaysbeen socioeconomicdifferentialsn

mortality evels andthattheypredated he

impactof modernmedicine.This situation

was partlya function of income and the

abilityto eat betterandenjoyothermaterial

comforts,as Malthusnoted.43But the evi-

dence on social differentials by ethnic

group,andof greaterpropensity or child

loss in some householdsthanothers,even

in ratherhomogeneouscontemporaryEn-

glish urban areas or Indianvillages, sug-

gests thatsocial differentialswere also im-

portant. t is unlikelythatresearchwill ever

identify pre-modern-medicine opulationswith no social differentialsin mortality,

especially child mortality,but it is highly

probable that the differentials will be

smaller than those in the era of modem

medicine. It should be noted thatthis era

did notsuddenlybegin.Moreover,modem

41. J. Spence et al., A Thousand Families in

Newcastle-upon-Tyne:An Approachto the Study ofHealth and Illness in Children(New York:Oxford

UniversityPress,1954).42. Monica Das Gupta,"DeathClustering,Ma-

ternalEducationand theDeterminants f ChildMor-

tality nRuralPunjab, ndia," nWhatWeKnowabout

Health Transition, d. Caldwell et al.

43. Cf. JohnC. Caldwell, "Family Changeand

DemographicChange:TheReversalof theVeneration

Flow," in Dynamics of Populationand Family Wel-

fare 1987,ed. K. Srinivasan ndS. Mukerji Bombay:

Himalaya,1988), pp.71-96;JohnC. CaldwellandPat

Caldwell,"FamilySystems:TheirViabilityand Vul-

nerability:A Studyof Intergenerational ransactions

and Their DemographicImplications" Paperdeliv-

ered at IUSSP Seminaron ChangingFamily Struc-

turesandLife Coursesin LDC's,East-WestPopula-tion Institute,Honolulu,HI, 5-7 Jan.1987).

medicinehas become ever moreeffective,so thatsocial differentialsnmortalityaris-

ing out of interactionwith modernmedi-cine are likely to have increased in the

presentcentury.The second propositionis that a sub-

stantialpart,probably he majority,of the

explanation orsocial differentialsn mor-

talityinthecontemporaryThirdWorld ies

in the interactionwith modernmedicine.

Evidence for the mechanicsof thisinterac-

tion is presentedat the end of this article.The interfacebetweensociety and modem

medicine is broader hantheproponents f

scientific medicineusually ike to admit.It

includes not only doctors, nurses, mid-

wives, and pharmacistsbut also pharma-ceuticals distributed through traditional

markets, by wandering untrained sales-

men,and,on a massivescale,throughboth

traditionalmedical practitionersand non-traditional untrained practitioners or

quacks. This informal system helps to

changebeliefs andpracticeswithregard o

illness and its treatmentand increasinglyactsas a referral ystemto the moreformal

health sector. It is also probablethat this

uncontrolledspreadof modern medicine

saves more lives rather hancauses addi-

tional deaths, althoughthe whole matterhas hardlybeen researchedat all. This in-

formalsector s theonlychannelof modem

medicine to muchof ruralSouthAsia and

sub-SaharanAfrica and almost certainly

plays a role in the continuingdecline in

mortalityin both regions. The impact of

modem medicinein the formal sector is a

function ess of its scientific levels thanof

its accessibility throughrural clinics andnationalhealth schemes reducingthe costto the patient.The breakthroughperiodsin reducing mortalitylevels in differentThird Worldcountries have been associ-ated with the democratization f services,

53



THE ANNALS OFTHEAMERICANACADEMY

not with an increase n the qualityof med-

ical technology.

The thirdproposition s thatthe varioussocial mechanisms dentifiedas playinga

role in reducingmortalityarereallydiffer-

entfacetsof thesamephenomenon,which

might be called social modernization,or

the rise of individualism rWesternization.It is really somethingbroaderandin many

ways is the socialcounterpartf thetransi-

tion from subsistence productionto the

marketeconomy.It is the move toward asystemwhere individualshaveoptionsand

canexercise choices- andrealizethat heycan do so and act on that realization.The

findingswithregardo maternal ducation,female autonomy,andgrass-rootsradical-

ism are all partof this picture. It is also

why sudden social shocks can accelerate

demographic rocesses,asthe FrenchRev-

olution and the Japanesedefeat in WorldWarIIdidin the case of thefertilitydeclineand as the Chinese Revolution did with

regardto mortalityeven if its stated aim

was farfrom the promotionof individual-ism. It is thedismantling f thesubsistence-

production organizationand the controland belief systems thatwas necessarytoensuresurvival.

Underlying these changes were pro-foundeconomicchanges.Itwas economic

growththatproduced he full market con-

omy andultimatelyallowed individualsa

degree of independencefrom the unified

familyeconomy.Nevertheless, n termsof

demographicbehavior,the shifts in belief

systemswereveryimportant.ntheareaofhealththe important hangeswere toward

a belief that sickness and death were theresult of nondivine andnonmagical orcesof thisworld,that herewas something hatcould be done about them in the form ofeithercarefulbehavioror seekingthebest

help,andeventuallythatmodernmedicinewas usually the most effective help that

couldbe obtained.In a studyareain rural

India,we called theprocesstheseculariza-

tion of healthbehavior.44 hatseculariza-tiondoes notnecessarily nvolveadiminu-

tion of religion, but it does involve its

retreat from intervention in causing the

everyday disasters of this world. In the

Indianvillage the decline of the so-called

little tradition nd tsvillage goddessesand

profusionof evil spirits,in the face of the

great tradition of mainstreamHinduism,

associatedwith literacy,courts,andcities,is an example of this, as was the Puritan

movement in England,which eventuallymoved ordinarypeople towardthe view

that mostearthlyphenomena n theirday-

to-day iveswere a matter f material ause

andeffect andthat o thinkotherwisecould

be blasphemous.It might be noted thatearlierbehavior was not irrational n that

much less could at that time be done toavertsickness and death.

The West experienced these changesfirst because of unparalleled economic

growthfromat least the sixteenthcentury.It was eventually to export some of this

growthas theworldmoved towardaglobaleconomy,but in theprocessit exported ts

behavioralbeliefs andsocial attitudesand

ultimately ts medical technologyand ac-

companyinghealth philosophy.This ex-

portwas achievedby colonialadministra-

tors, missionaries,the media, and, most

powerfully,by the moderneducationsys-tems thatareladen with Western,market,so-calledrationalvalues withregard obe-havior and family relationshipsand sys-tems. Theseconduitswere so effective be-cause they were hardlyconsciousof their

proselytizingrole butusuallybelievedthey44. John C. Caldwell,P.H. Reddy,andPat Cald-

well, "TheSocial Componentof MortalityDecline:An Investigation n SouthIndiaEmployingAlterna-tive Methodologies,"PopulationStudies,37(2):185-205 (July 1983).

54




were propagatingeitherobjectivetruthor

objectivelydesirablebehavior.Theimpact

of such ideological exportshas probablyplayed a central role in the near-global

fertilitytransition hatis occurring.45There is compelling evidence that the

impactof maternal ducationon child sur-

vival is notmerelya case of learningmore

abouthealth.Themostimportant vidence

is that it occurs everywhere: in goodschools with good teachers who do teach

about health and in poor schools with un-derqualified eacherswho devote no time

to thesubject,as well as ineverypartof the

Third World. Even strongerevidence is

providedby the linear mpactof education

so that even a little elementaryschoolinghas a proportionalmpact.Clearly,we are

witnessingthegeneral mpactof ideas,ide-

ologies, and behavioral models. In rural

Bangladesh,Lindenbaum oundthatmoth-ers who had been to school were cleaner

andraised heirchildrenmorehygienicallyandcarefully,not becausetheyhad earned

that hiswouldsavethe children's ives but

becausethey assumed hat thosewith edu-

cation behavedin such a superiorway.46n

a south Indianruralarea,we found that

motherswith schooling associated them-

selves and their schooling much moreclosely with "modern" nstitutions- inde-

pendence and five-year plans as well as

health centers and the case for using

45. JohnC.Caldwell,Theoryof FertilityDecline

(London:Academic Press, 1982), esp. chap.9, "The

Failure of Theoriesof Social and EconomicChangeto ExplainDemographicChange:Puzzlesof Modern-

ization orWesternization," p.

269-300.46. Shirley Lindenbaum,ManishaChakraborty,

and MohammedElias, "The Influence of Maternal

Educationon Infant and Child Mortalityin Bang-ladesh"(Reportfor the InternationalCentrefor Di-

arrhoealDisease Research,Bangladesh, 1983), re-

printed n SelectedReadings,ed. CaldwellandSan-

tow, pp. 112-31.

them-than did illiteratemotherswho felt

thatthey were not partof this new world.

The educatedalso felt thisabouttheuned-ucated,thusreinforcing helatter'smental

set.47

A corollaryof thisarguments thatma-

ternaleducation s likely to producemuch

greaterdifferentials n child mortalityin

the contemporaryThirdWorldthanin the

West,eventhehistoricalWest,becausethe

market-attunedehavioralsystem had al-

readyevolved in the West. This baldstate-ment might be modified by noting that

educationin the West did acceleratethe

workingclasses' adoptionof middle-class

values and that "rational ndividualistic"

behaviorhas continuedto develop in the

West. Prestonhasproducedevidencefrom

the U.S. census of 1900 to show thatthe

gapbetween educatedprofessionalclasses

andthe rest of the society in childsurvivalwas much smaller than in the contempo-

raryThirdWorldand evidence fromBalti-

morein 1915 to show only small differen-

tials between literateand illiteratemothers

once father's ncome hadbeen controlled.48

He arguedthat this was because the level

of healthignoranceof the middle class in

America of thattime was high and closer

to that of theworkingclass than s the casein thecontemporaryThirdWorld.I subse-

quentlycontested this view, partlyon the

basis of a social-historical tudyof health

behaviorin nineteenth-centuryAustralia,

47. JohnC.Caldwell,P. H. Reddy,and Pat Cald-

well, The Causes of DemographicChange:Experi-mentalResearch nSouthIndia(Madison:Universityof Wisconsin

Press, 1988), esp. chap. 6, pp.132-60

andchap.7, pp. 161-86.

48. Samuel H. Preston,"Resources,Knowledgeand Child Mortality:A Comparisonof the U.S. in

the Late NineteenthCenturyand Developing Coun-

triesToday,"nInternationalPopulationConference,Florence 1985 (Liege: InternationalUnion for the

Scientific Studyof Population,1985), 4:373-86.

55



THEANNALS OF THEAMERICANACADEMY

and maintained hat the lesser differential

was due to the fact thatmodern medicine

was much less developed and had rela-tively littleto offer.49 now believe thatmy

interpretation as onlypartof theexplana-tion and that the other partwas that, as

Western ducation'smessagewas so much

closer to the Westernbehavioralpatternof

the time, its impacton changingattitudes

and behaviorwith health mplicationswas

much less than in the contemporaryThird

World.It mightbe noted that PrestonandEwbank have produceda study showingU.S. child-mortalityrates by social class

wideningbetween 1895 and1925,"consis-

tent,"they argue"withthe fasteradoptionof behavioral innovations by the upperclass groups."50Amongthebehavioral n-

novations thatthey document s the grow-

ing resort to modern and increasinglyef-

fective medicineby professionalclasses.One furtherpointshould be made with

regard to education. All contemporaryThirdWorld data show a significant im-

pact on child mortality rom fathers'edu-

cation as well as thatof mothersandthat

much of this effect survivescontrolling or

income. Discussionhascenteredundulyon

the maternaleffect, even thoughthe exis-

tence of such an effect is good evidencethat education probably affects both afather'sattitudeand behaviorwith regardto his children's health and also his rela-

tionshipwith hiswife, with aresultant ec-

ondary mpacton his children'shealthandtreatment.

There is a related but distinct matterwith regard o children'shealth.That s the

49. Caldwell, "Routes,"p. 206.

50. Douglas C. EwbankandSamuel H. Preston,"PersonalHealthBehaviourand theDecline inInfantandChildMortality:The UnitedStates, 1900-1930,"in WhatWeKnow aboutHealth Transition, d. Cald-

well et al.

matterof the intrafamilialemotional and

resource-allocation priorities. These

change as the marketdevelops and withWesternizationbut are better treated as a

separate trand nsocialchange ikelytobeaccelerated or retardedaccordingto thenature of family structures. have calledthe intrafamilial low of resourceswealthflows and the changethatdirects more of

them toward childrenthanparentsor fa-thers the reversal of the intergenerational

wealth flows to a downwarddirection.51Thefourthpropositions thatchildmortal-

ity will fall more rapidly as the inter-

generationalwealth flow turnsdownward.

This almostinevitablyhappensas fertilitydeclines. Indeed, not only does parentalconcern for child survival ncrease,as has

happened n contemporaryChina,but sodoes communityand nationalinterest in

encouraging parentsto care for these in-creasingly rare and precious commodi-

ties, as happened n the case of the infant-welfaremovement ntheWest romaround1900 as the full extentof therecent ertilitydeclinebecame clear.Families arewillingto spendmoreeffort and a greaterpropor-tion of income on child care andsurvival.The situationis even morecomplex than

this because there is a correlation n theThird Worldbetween the level of familyplanningpracticeandchild survival evenbefore fertility decisively declines. Thereasonappears o be thatthe wealth flowhasbegunto turn; he familiesarealreadyplacingmoreemphasisonchildrenrelativeto theold, areplanning or theirfuture,are

findingthat the adequateallocation of re-

sources to each child for the successes ofthoseplanscan be attainedonlywithfewer

children,and are trying harderto ensuretheirsurvival.

51. Caldwell,Theoryof FertilityDecline.

56




ELABORATIONS

Two modifications need to be intro-

duced to this pictureof social and family

change.The first is that the rate of family

changedepends o a considerable xtenton

its preexisting structure.In sub-Saharan

Africa, partlybecause of the lineage sys-tem andpartlybecauseof widespreadpo-

lygyny, wives usually have separatebud-

gets fromthose of their husbandsandare

themselves responsible for many of the

resources neededby theirchildren.52 his

gives mothers a great deal of autonomywith regardto health decisions affectingboththeirown andtheir children'shealth,but it often severely limits the resources

available. In these circumstances, a

strengthening f thespousalemotionaland

economic bond,as well as any movement

towardmonogamy,

islikely

to accelerate

child-mortalitydecline.Similarly n South

Asia and elsewhere, nuclear-familyresi-

dence in contrastto extended-familyresi-

dence is likely to give the young mother

greatercontrolover her children's healthtreatment.In south India, education can

producea degreeof emotionalnucleation

even within the extendedfamily and can

givea mother

greatercontrol over health

decisions affectingherchildren.Thesecondmodification s thata strong

cultural radition imitingwomen's auton-

omy, especiallywhen reinforcedby a reli-

gion thatregardsthe seclusion of women

as a prime moral objective, can have a

deleteriouseffect both on female healthin

generaland on all child health because of

52. John C. Caldwell and Pat Caldwell, "The

CulturalContext of High Fertility in Sub-Saharan

Africa,"PopulationandDevelopmentReview,13(3):409-37 (Sept. 1987);JohnC. Caldwell,PatCaldwell,and Pat Quiggin, "The Social Context of AIDS in

Africa,"PopulationandDevelopmentReview,15(2)

(June1989).

the limitation n mothers' akingquickand

effective action. This is the majorreason

why the Arab world does conspicuouslybadly relative to income in attaining ow

mortality.Suchtraditions an limit theed-

ucation of women and can limit the health

effectiveness of thateducation.This iswhyin the WorldFertilitySurveyprogram he

differentials n child survivalby mother's

educationwere so smallinBangladeshand

why in Syria and Jordan,although they

were considerable etweenmotherswho hadneverbeen to school andthosewho had-

possibly a cultural or ethnic effect-theywere very smallby durationof schooling.

The finalpropositions thatcultural, o-

cial, andbehavioral actorshave animpactbothonan individual'smortalityandonthe

mortalityof anindividual'sdependents.So

muchanalysishasbeen carriedout on child

survival because demographers' tech-

niquesforestimatingmortalityevels from

most Third Worlddataare muchbetter at

the youngest ages. This has also allowed

the specific study of the impact of the

mother'ssocial characteristics, ecause of

the particularly mportant ole she usually

plays in the treatment f youngchildren.It

would beunwise, however,

to believe that

parentsplayedthe sole role inensuring he

survival of children.In muchof theThird

World,grandparentsndsiblings play im-

portantroles. The improvedrelative sur-

vival chance of girlsafter5 yearsof age in

South Asia shows that increasinglychil-drenplay a role in their own survival and

presumably,then, that their own social

characteristics re increasingly mportant.There are data now for Europeshowingthat mortality rates for adult males aremuch lower among the more educated,53

53. T.Valkonen,"SocialInequality nthe Faceof

Death," nEuropeanPopulationConference:Plenar-

ies, ed. International nionfortheScientificStudyof

57



THE ANNALS OF THE AMERICANACADEMY

evidence probablyof a firmer decision to

controltheirown lives andfate.Thedeter-

minantsofdependent

children'smortalityare a point of prime importance n high-

mortalitysocieties, for where life expec-

tancyis below 50 yearsand thepopulationis growing at 3 percentper annum,as in

sub-SaharanAfrica,the majorityof deaths

arelikely to be to personsunder5 yearsof

age.Witha life expectancyof 60 yearsand

a growthrateof 2 percent,however,as is

now found in SoutheastAsia,

thatpro-

portion drops to aroundone-quarter; nd

with a life expectancyof 75 years and a

growthrate of 0.5 percent,as now charac-

terizes the West, the proportionfalls to

one-fortieth.Hence, as mortality alls, the

emphasis on health behavior shifts from

parenthood o how the middle-agedlook

afterthemselves.

THE TRANSLATIONOF

BEHAVIOR NTOSURVIVAL

This section documents he fact thatbe-

havior,especially mother'sbehavior,can,inThirdWorldsocieties,be translated nto

lower child mortality.It focuses on rural

southIndia,with a life expectancyaround

50 years,and SriLanka,nearing70 years,areaswhere I have undertakenanthropo-

logical studiesof demographicbehavior.54

The term "health management" de-

scribes behavior that prevents sickness

Populationand theEuropeanAssociation forPopula-tionStudies,for theFinnishCentralStatisticalOffice

(Helsinki:Central tatisticalOffice,1987), pp.201-61.

54. Caldwell, Reddy, and Caldwell, Causes of

DemographicChange;JohnC. Caldwellet

al.,"Sen-

sitization to Illness and the Risk of Death:An Expla-nation for Sri Lanka'sApproach o Good Health for

All," Social Science and Medicine, 28(4):365-79

(1989);John C. Caldwell et al., "Cultural, ocial andBehaviouralDeterminants f HealthandTheirMech-

anisms:A Reporton Related ResearchPrograms,"n

WhatWeKnowaboutHealthTransition, d. Caldwellet al.

from occurringor limits the damageonce

it does occur.Greater emaleautonomyor

education ncreasesa woman'scapacity

n

healthmanagement n two ways: first,by

giving hergreaterdetermination ndself-

confidence and, second, by reducingthe

family and other constraintsplaced uponher. In traditionalsociety, child care is

oftena diffusedresponsibility.Galalel Din

showed how in aSudanesevillagechildren

were rathercasually looked after by the

wholevillage,

as well asby

theirsiblings,but, as mothers became more educated,

theytookgreater ontrolandresponsibilitythemselves.55A research program in a

north Indianvillage showed how women

in semiseclusion had little confidence in

theirabilityto identifysickness or to take

theappropriateteps.56n rural outhIndia,we foundthatmoreeducatedmothersgave

greateremphasisto

cleanliness, hygiene,nutrition,and the need for rest and sleepwhen childrenwere sick. Theywere more

effective in demanding from their hus-

bandsagreater hareof availableresources

for their children rather than for their

husband's relatives. When sickness did

occur, they were more likely to adoptef-

fective home action. This is an important

point,for home care is

reportedo consti-

tuteat east halfof alltreatmentntheThird

World.57

55. Mohamedel Awad Galal el Din, "TheEco-

nomic Value of Childrenin Rural Sudan,"in The

PersistenceofHighFertility:PopulationProspects n

the ThirdWorld,ed. John C. Caldwell (Canberra:Australian National University, 1977), 2:617-32;

idem, "The Rationalityof High Fertility in Urban

Sudan," n ibid.,2:633-58.

56. M. E. Khan etal., Inequalities

betweenMen

and WomennNutritionandFamily Welfare ervices:

AnIn-DepthEnquiry nan IndianVillage,PopulationandLabourPolicies ProgramWorkingPaperno. 158

(Geneva:International abourOffice, 1987).57. N. A. Christakis nd A. M. Kleinman, llness

Behavior and Health Transition n the DevelopingWorld,mimeograph Cambridge,MA: HarvardUni-

versity,School of PublicHealth,1989).

58




In southIndia,we studiedin detailthe

various interrelationsbetween sick chil-

drenandtheirfamilies on the one handandthe medical service on the other n a situa-

tion where one village in a ruralareahada

governmenthealth center with a resident

doctor.Thepersonwho first detectedchild

sickness was in 80 percentof the cases the

mother; however, illiterate mothers were

unlikely to take action or even draw at-

tention to the sickness, waiting for their

mothers-in-lawor husbands to take noteand action. One reason thatmortalitywas

higher in the south Indian research areathan ntheSriLankanonewas thatonly 10

percentof mothers n theformer ook treat-

ment action on their own responsibility,

comparedwith 50 percent n the latter.As

a mother's education increased,she was

more likely to be the chief proponentof

action when her children were sick andmorelikelyto ensure hat heyweretreated

by the doctor.

In the same study,one of the steepestdifferentialsby maternaleducationwas in

the time spentby themotherwith the doc-tor. Given the absence of backuplabora-

tory testing, diagnosis depends to a verylargeextenton case historiesas presented

by mothers. Doctors think that illiteratewomen cannotadequatelypresentsuch ev-

idence and make relativelylittle efforttolisten to them.Partlybecause of theirlackof educationandpartlybecausedoctors ayless tothem, lliteratewomenare ess likelyto carryout the doctor'sinstructionsprop-erlyand less likely topersistwith thetreat-ment.Avery steepandsignificantdifferen-

tialbyeducation s foundwithregard othemother'sreactionwhen the child's condi-tion does not improve.With moreschool-

inga mother s increasingly ikelyto return

to the healthcenter oreport heproblem o

the doctor, while an uneducatedmother

frequently fails to do so partly on thegroundsthat the doctorhas alreadydone

his best andpartlyon the grounds hatshe

cannottell animportantman he hasfailed.

When we contrasted his situationwith

Sri Lanka,with its much higherlevels of

femaleeducation,we found n theSriLan-kanhouseholdan almostcompetitiveatti-

tude to thequickdetectionof sicknessand

the seeking of treatment. The strongestcontrast, however,was in the Sri Lankan

impatiencewith treatmenthatwas notre-

sulting n improvement ndtheconsequent

changing of doctors or from doctors to

hospitalsafter only a few days. The low

mortality evels suggest that this is an ef-fective treatment trategy.

THEDIRECTIONOF CHANGE

In most of the Third World,with its

limitedandonly slowly spreadingmodem

healthservices,mortalityevels canbe dra-

maticallyreducedby behavioralchanges.Those changesare not easily achieved,as

theyaffect notonlymortalityevels but thestructure f societyand all social relations.

Nevertheless,there is a potential or rapidchange that did not exist in the Westbe-

cause Westernsocial patternsare spread,

largelywithoutthataim in mind,by educa-

tion, the media, and religious proselytiz-

ing.Educationhas had a major mpact,andthisis now being supplementedby the wo-men's movement.Underlyingit all is the

development f themarket conomyandac-

companyingmovements way rom hefam-ily controlpatternsandresourceprioritiescharacteristicf subsistence griculture.

59

Cultural and Social Factors Influencing Mortality Levels in Developing Countries

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