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.
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.
The essence of epidemiologic field trials is the RCT (randomized control trial). A random set of people get some sort of treatment (like a new drug), another random set of people don’t and we compare the results. It’s pretty simple stuff.
The trouble with RCTs is that they don’t necessarily work well when people from the two groups are able to influence each other’s outcomes. As a simple example, a trial of a vaccine which prevents people from getting infected with some pathogen might have impacts on people who don’t get the vaccine, since the number of opportunities for transmission are reduced. This is a welcome outcome (and may even be the point of the study), but it doesn’t help us to understand exactly how effective the vaccine is in the individuals who actually receive the vaccine.
Many RCTs make the (flawed) assumption that individuals are independent entities, following a long tradition of statistical analysis. This is a reasonable assumption to make in some cases, but entirely wrong in others (i.e. most public health outcomes).
Development economists have recently adopted the RCT as a means of evaluating the effectiveness of programs intended to relieve poverty or improve human well-being. On the surface, there’s nothing wrong with adopted public health methods to deal with economic problems, as most public health problems have their roots in economics. Jeff Sachs, or course, would argue that many economic problems have their roots in public health problems.
The major problem with RCTs is that while we do our best to control for all of the possible other factors that might impact outcomes given a particular treatment, without a trove of detailed data and prior knowledge of context and contingencies, we really have no idea at all whether and how some public health intervention works. Epidemiology tends to fall back on the “reasonable suspicion” argument, backing up claims of effectiveness with potentially reasonable assumptions of causal pathways. This is clearly quite easy when doing drug trials, where animals models and a century-plus of medical research has given us a reasonably clear pictures of the pathophysiological pathways that might lie between drug and outcome.
But with issues of human behavior and economics (which is essentially a science which seeks to uncover mysteries of human behavior), the causal pathways are much more difficult to assess and the factors which lie between intervention and outcome are for more difficult to measure. For example, assessing the outcome of an education program on reproductive behavior is really, really difficult without monitoring all of the possible things that happened between the time that a woman attended an NGO sponsored event at a clinic and the time when she chose to use or not use a condom. In fact, we can’t even really verify that she used the condom, since we weren’t around to observe it.
But we assume, and assume to the point of falling back to faith that our efforts did what we intended them to do.
Lant Pritchett, a Harvard economist that I’m a great fan of for his work on economic measurement in developing countries, penned an interesting article on the website of the Center for Global Development seemingly questioning the merit of the RCT as an rigorous and necessary evaluation tool for poverty alleviation development programs.
First of all, the argument that RCTs had, until recently, been used sparingly, if at all, and yet are important in achieving good outcomes sits in kind of embarrassing counterpoint with the obvious fact that lots of countries have really good outcomes. That is whether one uses the Human Development Index or the OECD Better Life Index or any social indicator—from poverty to education to health to life satisfaction—there is a similar set of countries near the top. (In the HDI the top five are Norway, Australia, USA, Netherlands, and Germany. In the OECD Better Life Index they are Australia, Sweden, Canada, Norway, and Switzerland.) No one has ever made the arguments that these countries are developed and prosperous because they used rigorous evidence—much less RCTs—in formulating policy and programs. While one might have faith that RCTs can help along the path to development, RCTs didn’t help for those that are there now.
It is very true that development in the United States occurred without the help of RCTs. In fact, malaria elimination in the United States occurred without any of the complex set of interventions that we’re so desperately selling to malaria-endemic countries. It’s even true that, despite more than a decade of research on ITNs, that we aren’t really sure whether the declines in malaria that we’ve seen all over Sub-Saharan Africa are due to ITNs or just simply due to processes associated with urbanization and development (as in the US). Actually, a lot of research is telling us that the declines in malaria might be false and that we are simply suffering from a paucity of accurate measurement in malaria endemic countries.
And this is where Pritchett comes in. He’s right. Research in developing countries is inherently challenging to the point where the conclusions we draw from research are somewhat contentious at best, and the result of blind faith at worst.
But coarse and incomplete data and loose assumptions shouldn’t discourage public health (or even economic) professionals from doing research in developing countries. While I have issues with the condescending, neo-classical nature of RCTs in economics (another discussion, but can a peasant lady’s behavior in Western Kenya be reduced to that of Homo economicus? ), the truth is that policy makers don’t care about data. They care that people are making the case for action in an impassioned and convincing way. While academics should strive to be as rigorous as possible, the sell won’t happen based on our complex data collection strategies and statistical methodologies. They (and the public) are convinced through impassioned calls for action.
We went and visited Kwale, a relatively small community of Duruma and Digo in Eastern Kenya. I’ve been to so many of these African towns that I’m honestly somewhat bored. Five years ago, I might have been more excited. Perhaps I’m just tired.
People speak Swahili here. For real. In the rest of Kenya, Swahili is a language to connect disparate tribes, Kenyans happily mangle and make a mess of Swahili, but it does its job well enough. Here, I’m struck that even the kids speak Swahili, something you never see in other parts of Kenya.
I keep running into people who don’t speak anything but Swahili forcing me to communicate as best I can with my limited vocabulary. Fortunately, it’s all easy to understand out here.
But, to be honest, it’s quite boring out here. Life is fairly content, it lacks all of the huge and obvious problems of economics and health that persist in the rest of Kenya, and the ubiquity of Islam makes is a safe and tranquil place, if one is willing to ignore the oppressive patriarchy.
We spend the day at the hospital, meeting person after person. I’m growing agitated. Lunch is being pushed back later and later. I’m so bad at this, but its necessary and everyone is well meaning and kind.
Why are we doing this? All of Kenya’s problems are a failure of government. It’s not fashionable to say, but you can’t help but be annoyed when people spin the tired old narratives of colonialism and corruption. You guys voted these assholes in.
We finally get to lunch. I order pilau (mixed rice and beef) and some fried goat, knowing that it will be quick and we can be back on the road. Since he’s not paying, our Kenyan host orders to most expensive thing on the menu, the thing they never have prepared, the thing you have to wait an hour for. It’s hard not to be annoyed, but you just let it slide.
People are telling me what a great President Moi was, claiming that everything was ok during his reign. It was at the beginning, thanks to his predecessors, but his awful policies pushed Kenya to a horribly repressive one party state and spurred a complete collapse of the Kenyan economy, leaving the mess for his successors to clean up. In politics, timing is everything.
Now the entire health system has been devolved to the provincial governments. I’m thinking this is going to become a disaster of epic proportions. While the devolution of powers to local governments makes some sense in diverse and fractured Kenya, health problems usually don’t recognize political boundaries. A failure of health policy in HIV and malaria infested Nyanza could have devastating effects for Nairobi.
We’ve stopped in a tiny market center in the middle of nowhere. I say “shikamoo” to an old man, a respectful greeting reserved for elderly people. He asks me for 20 schillings. I’m having fun saying “shikamoo” to people younger than I am. It confuses the hell out of them.
The area is partially semi-arid and partially forested. Elephants come out of the national park and wander through the streets, I’m told. Baboons rifle through the trash. The areas close to the forest are doing better than the other areas, but there’s no real economy out here and the wildlife and igneous terrain prevent people from doing any substantial agriculture out here. The houses are in great shape, some even have power, but there’s malnutrition everywhere. The markets are mostly devoid of decent food outside of bags of rice trucked in from other areas. There are signs of American food aid and a World Food Program truck passes us.
A Japanese group is doing a survey on diet and malnutrition. It’s explained to me, but I think it’s pretty stupid. We already know that a lack of food causes malnutrition. They say they want to help. While I’m listening, though, I’m thinking that it’s a colossal waste of time and money. Perhaps it might be more helpful to come up with a better plan.
I realizing that this post is full of complaints, but here not every day is full of wonder and excitement.
We get dinner. It’s nyama choma (BBQ) again. I’m not disappointed but the conversation turns to Japanese academics. I can’t help but remark that I find a lot of it horribly uninteresting. I’m not sure why many of these groups do projects here, and even less sure what the tangible results will be, outside of raising the domestic status of ineffective Japanese researchers. Public health research really has to do one of two things. Either it should push science forward, or provide meaningful public health services to developing countries. The projects that are being described to me fail on both points. My anxiety level is high.
It’s time for me to stop complaining, though complaining is healthy and sometimes leads to substantive change. I’m getting ready to go to get some Ethiopian food at one of my favorite spots in Nairobi, Queen Sheba, which is run by Ethiopian refugees who fled the war there some years ago. Fortunately, it’s not expensive, unlike other places in Nairobi. See, the complaints never stop.
Does malaria facilitate the development of exploitative agricultural estates? Interview with Dr. Luis Chavez
My friend Luis just published a paper in PlosOne on land consolidation or the formation of “latifundia” in Spain. Latifundia were large agricultural estates owned by the Romans, often dependent on slave labor, the growth of which has been implicated in Rome’s fall.
Luis creates a mathematical model to describe the formation of these large estates. He then tests the hypothesis that malaria transmission exacerbated the situation, by forcing land owners to sell cheaply to opportunistic land owners in less malarious areas.
Luis, an ecologist who works on issues of disease transmission (and all around great guy), is somewhat unique in the world of quantitative sciences. He took a few minutes to talk to me so that you can see why.
Who are you and what’s your background?
If you ask the japanese they might say: O gata no hen na gaijinsan. As to my academic background, I studied biology/parasitology as an undergraduate, then mathematical ecology for a M.Sc. and then was granted a Ph.D. in ecology and evolutionary biology (note: at the University of Michigan).
Nevertheless, I have always been interested in the humanities, especially history since it gives the best vantage point to understand the present. I grew up in a household where mixing things/topics was usual. Both my father and grandfather went to grad school, something unusual in Latin America, and since i was child lunch time talk was heavy on the side of human rights and solidarity, science and the need for change. When Nelson Mandela died i remembered that a lovely family activity during my childhood was going to a cultural/educational event in solidarity with Nelson Mandela and the South African people to end the apartheid.
For lay people, what’s the paper about and what motivated you to explore it?
The paper presents a mathematical model that can explain the formation of latifundia (large estates) when the profitability of land varies across landowners in a landscape. The model is also used to show that when such differences are not present latifundia still can emerge if there are differences in the risk of acquiring an infectious diseases. I built the model based on historical records to show that both patterns have been observed in societies as different as “latin” Europe (Italy and Spain) and China.
What’s a “latifundium” in Spain? I dug around a bit and could find some things about Rome and Latin America, but not so much about Spain. Why choose Spain?
A latifundium is a large estate, which requires the labor of people that do not own the land. I chose Spain because a essay by Chantal Beauchamp presented a couple of striking maps showing that places where malaria was common were those where Latifundia were common during the 1930s (Fig. 2): http://www.persee.fr/web/revues/home/prescript/article/ahess_0395-2649_1988_num_43_1_283483
The pattern of association between malaria and latifundia was not new, but only Beauchamp had data amenable for a quantitative analysis.
Are you trying to say that malaria helped enable capitalist land appropriation?
It might be the case. The hypothesis that malaria helped to enable land appropriation was put forward by the great italian malariologist, Angelo Celli. He has a book on the topic [reference 8 in the paper, available at the UMICH SPH library]. Celli was probably the most advanced malaria epidemiologist at the turn of the 20th century.
Unfortunately, he and other italians [most notably Grassi] were blackbolded in the Anglo-Saxon world because they threatened the ego of Ronald Ross by saying malaria was not just due to a parasite transmitted by the bite of a mosquito [a biological fact that, nevertheless, they independently showed and published in Italian]. If you are interested just check the oldest records for malaria in the Nature archives.
Though issues of land tenure are very different in the US (given that we killed all the natives and stole it all), we did have some big and awful land plantations in the South along with a serious malaria problem. Might we also try to apply this to the United States, and, if so, how?
I think it might have helped to the consolidation of large estates in the south. Interestingly in the Midwest you never had the latifundia observed in the south, but you had malaria in Michigan (the midwest) at some point (See Humphreys M. 2001. Malaria: Poverty, Race, and Public Health in the United States. Baltimore (MD): Johns Hopkins University Press.).
Nevertheless, in the south due, for example, to Jim Crow laws there might have been a differential risk of malaria infection not observed in the Midwest. However, i found no data to go beyond speculation, well other that in the Canal Zone the Jim Crow housing organization showed the differential malaria risk: http://www.jstor.org/stable/10.1086/529265
I find these quantitative approaches to historical problems fascinating (I also started work on a paper on malaria in post-conflict Angola, maybe I should publish it). Do you think applying these methods to history as informative to present day problems? If so, how?
I think so, history probably gives the best vantage point to understand the present (Rendering history a tinker damn’s is a good strategy to sell things no matter if they are useful or even safe, Henry Ford was clear about this). In theory failures can be highly educational, something the model suggests is that equity in land tenure is an unstable equilibrium that could only be maintained by an external policy as the Chinese did before the An Lushan rebellion, and that any kind of unfair land redistribution could only be expected to not work (latifundia will be eventually formed), as observed over and over in most Latin American nations.
The mix of methods is rather novel. However, in the discipline focused and partitioned environment of academia, do you find that its hard to get an audience for this kind of work? Is there a future in it?
I can tell you this stuff is only suitable for publication on the Arxiv.org or PLoS One/ Springer Plus, if you want it to be peer reviewed and you don’t sign your paper with an address in Princeton or Oxford. I think the audience does not belong in any department, though scholars working on the diverse fields of ecology, health, sociology, maths, economics and even history might find it interesting. I think there is some future, there is the emerging field of cliodynamics that looks at historical dynamics and there is even a journal for cliodynamics where they, every once on a while, publish good food for thought like this paper: http://escholarship.org/uc/item/1ks0g7dr#page-1
I thought my data was not dynamical enough, so I didn’t try there.
This work is heavily political. Do you think there is a place for politics in science?
I think everything gets embedded in politics. Otherwise there would have been no shutdown in the CDC and other US government agencies few months ago, etc. I don’t think my work is more or less political than a risk factor analysis for lung cancer and smoking. I think i might be blackbolded by some of the references I cited, but to understand Capitalism even the Catholic Church is studying Marx [Funny the leading scholar is the Munich Bishop, whose last name is Marx]: