What are we talking about when we discuss socio-economic position and health in developing countries?
A wide body of literature has found that socio-economic position (SEP) has profound impacts on the health status of individuals. Poor people are sicker than rich people. We find this relationship all over the world and in countries like the United States, it couldn’t be more apparent.
Poor people, particularly poor minorities, are more likely to see their children die, are more likely to be obese, have worse cardiac outcomes, develop cancer more often, are disproportionately afflicted by infectious diseases and die earlier than people who are not poor. There is ample evidence to support this.
However, the exact factors which lead to this disparity are up to debate. Some focus on issues of lifestyle, diet, neighborhood effects and access to health care. Poor people, particularly minorities, live hard, eat worse, live in dangerous or toxic environments and have low access to quality care all contributing to a perfect storm of dangerous health risks.
However, even when controlling for all or any of these factors, we still find that poor people, and particularly African-Americans, still get sick more often, get sicker and die earlier. This leads us to speculate that health disparities are not simply a matter of access to material goods which promote good health, but are tightly related to something less tangible, such as social marginalization and racism, which are both incredibly difficult to measure. Though difficult to quantify, however, we do have plenty of well documented qualitative and historical data which indicate that these relationships are entirely plausible.
The awful history of slavery and apartheid, however, is somewhat (but not completely) unique to the United States. Further, our ideas of class come from another Western idea, the Marxist concept of one privileged group exploiting the weak for their own financial gain, particularly in the context of manufacturing.
Yet, though these ways of conceiving of race and class are so specific to the West, they are applied liberally to analyses of developing country health, with little consideration of their validity.
It is not uncommon to see studies of socio-economic status and health. The typical method of measuring socio-economic status in developing countries is to examine the collection of household assets such as TVs, radios, bicycles, etc. and, using statistically derived weights, sum up all of the things a household owns and call that sum a total measure of wealth. The collection of total measures for each household are then divided into categories, with the implication that they roughly approximate our conception of class.
Not surprisingly, it is usually found that people who don’t own much are, compared with people who do, at higher risk for malaria, TB, diarrheal disease, infant and maternal mortality and a host of other things that one wouldn’t wish on anyone.
But this measure is problematic. First, there is often little care taken to parse out which items are related to the disease of interest. For example, we would expect that better housing conditions are associated with a decreased risk for malaria, since mosquitoes aren’t able to enter a house at night. We would also expect that people with access to clean water would be more likely to not get cholera. If we find relationships of SEP with malaria or diarrheal disease which include these items, these associations should be treated with suspicion.
Second, if we do find a relationship of “class” with health, can we view it in the same way in which we might view this relationship in the United States? A Marxist approach, with a few exploiting the many for profit, in sub-Saharan Africa doesn’t make a whole lot of sense. The manufacturing capacity of African countries is tiny, and most people are sole entrepreneurs operating in an economy that hasn’t changed appreciably from pre-colonial times. Stripping away any requirements of legal protection of property rights, Africa looks incredibly libertarian.
Further, the elite in Africa hardly profit financially from the poor, receiving their cash flows mainly from abroad in the form of foreign aid or bribery and foreign activity is mostly limited to resource exploitation, which doesn’t make a dent into Africa’s vast levels of unemployment. While the West is certainly complicit is Africa’s economic woes, post slavery, the West rarely engages Africans themselves.
So, is it valid to attempt to apply the same ideas of class to African health problems? Is there a way to attribute health disparities to class in societies with limited economic capacity and where the “citizenry” is only marginally engaged and groups suffer mainly from a reluctance to cooperate and engage people of other tribes or neighboring countries?
Certainly, the causes of poverty and marginalization in Africa need to be examined, but I don’t think that we can approach them in the same way we do in the States.
I was part of a short, but interesting discussion last night regarding this very good article on the political implications of data analysis. The argument made (assuming I understood it correctly) was simply that statistical measures are inherently ideological since they impose a particular view of the world from one social group (us, the elite) on another (the non-elite). She takes this further, stating that though the voice of the elite can be heard through anecdotes (and opinionated blog posts), the experience of the non-elite relies on statistics and numbers. Statistics, then, is the language of power.
The conversation went further to discuss the implications of statistical methods themselves, particularly the measures of central tendency: the mean, median and mode. With perfectly symmetrical data, these measures are all the same, but, of course, no set of data is perfectly symmetrical, so that the application of each will produce different results. Though any responsible statistician would make statements of assumptions, limitations and appropriateness, with politics, these statements are overlooked and the method chosen is often that which best supports one’s political position, asking for trouble.
Moreover, the measure of central tendency itself in inherently flawed since it concentrates on the center and silences the extremes, supporting the status quo, or so it was argued. The choice of measure, I would argue, depends on the goals of the particular study. For example, a study which sought to determine if average graduation rates lower for blacks than whites would necessarily use a measure of central tendency, while a study on which students in a particular school are the least likely to graduate might look at outliers and extremes.
Either way, I agreed with the writer that, no matter what, we are influenced by our ideology. However, there is a difference between performing a study which seeks to maintain impartiality for the greater good and one which seeks to deceive in order to merely win a political battle, particularly among those who benefit from marginalizing, for example, the poor and disenfranchised.
However, I found this passage quite interesting and it can be applied to a post on this blog regarding what we do and don’t know about the poor:
Perhaps statistics should be considered a technology of mistrust—statistics are used when personal experience is in doubt because the analyst has no intimate knowledge of it. Statistics are consistently used as a technology of the educated elite to discuss the lower classes and subaltern populations, those individuals that are considered unknowable and untrustworthy of delivering their own accounts of their daily life. A demand for statistical proof is blatant distrust of someone’s lived experience. The very demand for statistical proof is otherizing because it defines the subject as an outsider, not worthy of the benefit of the doubt.
Part of my academic work focuses on the refinement of measurements of poverty. I am keenly aware of the “othering” of this process and how these measurements use a language of the educated elite (me) to speak for the daily experiences of people not like me.
This “othering” is not limited to statistics at all. Even merely referring to “the poor” is a condescending labeling of a group of people who are mostly powerless to speak for themselves within global power structures. Moreover, “the poor” ignores the diverse and varied experiences of most of humanity.
When I first entered the School of Public Health at UM, I was extremely uncomfortable with the language used in studies of ethnicity and public health in the United States. Studies would simply throw people into simplistic categories of black, white, hispanic, asian and “other” (whatever that is), ignoring the great diversity of people within, for example, urban slums. The method of categorization seemed to be a horrible anachronism and bought back awful memories of Mississippi. Simply putting people into neat categories risked continuing an already divisive view of the world.
However, the more I thought about it, the method is justified since we are looking at the effects of a racist view of the world on the very people who are the most burdened by it. Certainly, there are better ways of viewing the world, but when criticizing social power structures, it can be advantageous to speak its language. I still don’t like it, but I’m at least more understanding of it.
It’s a fine thread to walk. On the one hand, as advocates for “the poor,” we have to work within the very structures which oppress, exploit and ignore them. To succeed, however uncomfortable it may be, we may be required to adopt the language of those structures. On the other, we must remain aware of the potentially dire implications of the ways in which we describe those we advocate for and how they can be misused.
Often people will mention that we are “adapted” to do this or another thing, either indicating some crime of modernity (of course, ignoring the fact that a larger percentage of babies are surviving and people are living longer and healthier than at any time in human history) or trying to point out some example of the glaring perfection of our creation, with either an implicit or vocal reference to divine creation.
For example, obesity is attributed to fat and protein rich modern diets since we aren’t “adapted” to eat these types of foods (despite having found the food in East Africa so unpalatable that we had to learn to crush or cook it to digest it efficiently). Our bad disposition is blamed on a lack of sleep since we aren’t “adapted” to sleep as little as we do (this might be true). Most recently, a book writer blamed our problems with depression on a divorced relationship to nature, given that we are “adapted” to hunt and kill for food and then revel over the blood stained corpse (of course, the writer doesn’t consider that people in antiquity might have been depressed, too).
There may be some truth to some of this. However, “adaptation” implies something about the individual, when evolution, in fact, is about reproduction. We aren’t “adapted” to anything. Rather, certain traits are selected for based on the survival of at least two generations of living things, at least for complex social animals like ourselves.
Simply surviving as an individual does not insure the survival of a species. Living things must first survive long enough to reproduce and then, at least in humans, insure that the children make it to reproductive age. Human babies are horribly weak in contrast to sharks, which are ready to go even before they leave the mother. Further, in the case of humans, a full three generations must live at once to insure long term survival.
Thus, we maintain a tenuous relationship with out environment, where traits do not necessarily favor a single individual, but rather an entire family unit, and these traits may or may not imply perfect harmony with an environment, but rather do the job at least satisfactorily.
Nature cares little for quality as numerous examples throughout our physiology show. To claim that we are somehow “perfectly suited” to a specific environment is just simply wrong. Merely, we have come to a brokered peace (after generations of brutal trial and error, what we eat today is thanks to the deaths of millions, mostly children, who had to die to allow us to do so) with wherever we live in order to allow a few of our kids and grandkids to survive.
This, of course, has deep implications for public health. Some public health problems are known to be passed down from parents to children, but in a multi-generational evolutionary framework, it is possible that certain public health problems can be passed through 3 or more generations at a time, complicating interventions. Certainly, the multi-generational health problems of the descendants of African slaves can be an example of this. How can we intervene to protect the public health over a full century?
OK, back to work.
Same thing. Wrong way down an unmarked one way. Cop at the end. After arguing with him for a bit, I threw 1000 schillings at him and just left.
I was just reading a post from development economist Ed Carr’s blog, where he reflects on a book he wrote almost five years ago. Reflection is a pretty depressing excercise for any academic, but Carr seems to remain positive about his book.
He sums it up in three points:
“1. Most of the time, we have no idea what the global poor are doing or why they are doing it.
2. Because of this, most of our projects are designed for what we think is going on, which rarely aligns with reality
3. This is why so many development projects fail, and if we keep doing this, the consequences will get dire”
Well, yeah. This is a huge problem. In academics, we filter the experiences of the poor through a lens of academic frameworks, which we haphazardly impose with often no consultation with our subjects. Granted, this is likely inevtiable, but when designing public health interventions, it helps to have some idea of what the poorest of the poor do and why or our efforts are doomed to fail.
I remember a set of arguments a few years back on bed nets. Development and public health people were all upset because people were seen using nets for fishing. The reaction, particularly from in country workers was that poor people are stupid and will shoot themselves in the foot at any opportunity.
I couldn’t really understand the condescension and was rather fascinated that people were taking a new product and adapting it to their own needs. Business would see this as an opportunity and would seek to figure out why people were using nets for things other than malaria prevention and attempt to develop some new strategy to satisfy both needs (fishing and malaria prevention) at once. Academics simply weren’t interested.
To work with the poor, we have to understand them and understanding them requires that we respect their agency. If we don’t do this, we risk alienating the people we seek to help.