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.
We have no idea what poor people do
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.
Does the environment cause poverty?
African countries are blessed with ample cropland and resources, but suffer from crippling and unforgivable levels of poverty, have some of the shortest lifespans on the planet and the highest rates of infant mortality in the world. Meanwhile, Japan, Korea, Sweden, Switzerland and Singapore are wholly the opposite, yet mostly lacking in everything that Africa has. Clearly, the picture is more complicated than merely having access to a natural resources.
However, within countries, the picture might be different. African countries are complex and diverse places. Poverty is often confined to the most unproductive regions, areas with poor soils, poor rainfalls or dangerous terrains.
I was just working with some socio-economic data from one of our field sites, and noticed some interesting patterns (note the map up top). In Kwale, a small area along the Coast, socio-economic levels vary widely, but neighbors tend to be like neighbors and patterns of socio-economic clustering emerge.
Note that the poorest of the poor are concentrated to an area in the middle, which I know to be extremely dry, difficult to get to, difficult to farm and generally tough to live in.
I tried to see if socio-economic status (as measured through a composite material wealth index a la Filmer and Pritchett but using multiple correspondence analysis rather than PCA) was related to any environmental variables that I might have data for.
I fit a generalized additive model using the continuous measure of of wealth from the MCA as an outcome. Knowing that very few things in nature or human societies are linear, I also applied smoothing to the predictors to relax these assumptions. The results can be seen in the plot at the bottom.
A few interesting things came out. While it is hard to tell much about the poorest of the poor, we can tell something about the most wealthy. The richest in this poor area, tend to live in areas with the richest vegetation (possibly representing water), a high altitude (low temperature), high relief (no standing water) and in locations distant from a wildlife reserve (far from annoying and dangerous wildlife).
I’m not sure the wildlife reserve is meaningful (unless the reserve was an area undesirable for human habitation to begin with), but the others might be and represent a trend seen in other Sub-Saharan contexts. Areas without malarious swamps and ample farm land tend to do the best. Central Province, one of the most developed areas of Kenya, would be an example.
But the question has to be, does a harsh environment doom people to poverty, or do people self shuffle into and compete for access to more favorable areas? Is environmentally determined poverty (or wealth) an accident of birth, or the result of competitive selection?
Alright, back to work. Oh wait, this is my work. Well….
To Raise the Minimum Wage or….
In my morning reads, I found this article from Ezra Klein. Apparently, economists widely agree that raising the minimum wage will reduce poverty.
Klein’s article mostly centers around a paper from Arindrajit Dube. Using models, he found that raising the federal minimum wage from the current $7.235 to $10.10 would reduce the number of people in poverty by 2.4%, largely agreeing with studies from other economists.
To me, this in encouraging but wholly unsatisfying. If we assume that approximately 50 million Americans live in poverty, this would mean that 1.2 million Americans would no longer be classified as poor. Certainly, this would be touted as a success.
However, noting that nearly 48 million Americans would still be impoverished, I can’t help but feel that the effort would have been wasted. Worse yet, I wonder how prices and employment might be impacted by a nearly 33% increase in wage costs. Here, there seems to be little consensus among economists.
The more I think about it, the more I like the idea of a redistributive “negative income tax” which provides direct cash payments to households based on income earned. Before my conservative friends get upset, I would point out that (depending on who you ask) the idea was originally proposed by conservative, free-market, University of Chicago school economist Milton Friedman. The present Earned Income Credit is based on his model.
So here are my (non-economist) points, all of which are completely up for debate:
1. Cash payments from government proportional to income earned would benefit far more people than those on the bottom income rung. The goal would not be to merely “alleviate poverty” but to also bring up the economic profile of all households below the current income median. I find the current discussions of raising the minimum wage to be incredibly myopic. I don’t know who raising the federal minimum wage will alleviate the greater problem of economic inequality in the United States.
2. It would have the effect of pro-actively alleviating poverty while still insuring employment and a health economy. Businesses would be motivated to maximize employment and would have little reason to insure that workers stay on the bottom. Small businesses would also have more leeway with which to figure out how to provide health or retirement benefits to workers.
3. Cash transfers would presumably reward increases in income within the bottom 25% of wage earners and gradually begin to taper off as incomes become healthy and sustainable. Tapering would be important. Welfare payments are often too regressive. They punish households for escaping poverty by cutting off benefits. Not only does this send an odd message to American workers, it also encourages hidden sources of income complicating taxation and the payment of wages below the federal minimum wage. Work in the shadows is not a pretty thing.
4. It would feed money directly into the economy and possible into communities. Households which have trouble saving would now (as with the EIC) receive lump sum payments with which they can purchase big ticket items, put a down payment on a new place to live, or even save the money so as to invest or start a business later. The biggest hurdle that entrepreneurs face is a lack of access to start up capital.
5. It would be equitable. Minimum wage increases risk regional efforts to circumvent them. As noted in 3) direct payments to households would help avoid the problem of “under the table work” which often preys on the weakness of workers.
Of course, this begs the problem of how to finance such a system. Barring the details (and potentially another post), I would suggest that federal sales (consumption) tax or a value added tax such as those in Scandinavia. This tax would exclude housing, food and education, but be applied to consumer goods and services. More on that later.
So that’s my take. I think that raising the minimum wage is a good step, but merely a Band-Aid on a greater problem. What do you think (all 10 of you)?
The Poor and their Teeth: What to Make of Linda Tirado
Actually, looking at the large amount of material that doesn’t make it to this blog, I noticed that more than half of it deals with my personal experiences with poverty. It appears that I think on my experiences quite often, but I’m hesitant to share them. Perhaps it’s fear of being seen as wanting sympathy or just simply that I don’t want think about it. .
The intro to the article struck me:
“There’s no way to structure this coherently. They are random observations that might help explain the mental processes. But often, I think that we look at the academic problems of poverty and have no idea of the why.”
It’s quite easy for me to have an academic discussion of the causes and implications of poverty. In fact, it’s my job to. It’s much harder to talk about my own experience with poverty, as it’s a collection of disjointed, chaotic and often incomprehensible experiences that don’t fit well into a tight flowing narrative. I’m sensing that Linda feels the same way and wonder if my reticence might stem from the difficulty of making sense of the chaos.
Linda’s credibility has been called into question. The article that she wrote for her blog is being seen and a clever ploy to extract money from sympathetic readers to fund her dubious book project. To make matters worse, she is multi-lingual, attended private schools as a child and has run a political blog since 2011.
Now, I can’t really comment on what Linda’s goals were in writing the original post or whether her claims are true. I don’t know Linda and won’t embark on a mission to either support or discredit her. The last sentence in the above paragraph struck me though since it also describes the author of this blog (me).
I grew up in awful, awful poverty. The kind that doesn’t ring in pictures of well meaning, hard working folks trying to get by under challenging circumstances. No, my poverty is due to a long family history of abuse, irresponsibility, alcoholism, mental illness and violence. My story is so incredibly extreme that it doesn’t usually elicit sympathy, but rather disgust.
What Linda and I share is that we don’t fit the picture of poverty. We’re white, educated and have it together enough in adulthood to string a few sentences along and have people read them.
My “poverty cred” is often called into question. I think this is natural. In America, we have decidedly fixed ideas of what poverty is and isn’t. It’s hard for many Americans to imagine poverty, and wide collection of experiences make it almost impossible to adequately relate a concise narrative.
Honestly, I never know where to begin with my story of poverty, but my top class education and advanced degrees don’t erase it. My younger brother came from the same situation I did (though from a different father) but instead of collecting degrees, he’s in and out of jail (and the hospital when his girlfriend stabs him). I was extremely lucky.
What Linda and I do share is our teeth. My teeth are bad. I have too many of them for my small mouth and my family were too dysfunctional and mired in insanity to do anything about it. In America, bad teeth are like a glowing neon sign that says “I WAS POOR.” If you have bad teeth and are young, people know what’s up when you smile. (What a relief egalitarian Japan was, where even pop stars have bad teeth!) When you run into someone else with bad teeth it’s a moment of bonding, like war tattoos.
I used to be ashamed of them. Now I wear them like a badge of honor, like a middle finger to the world, irrefutable proof that these awful things happened.