International Health. Dr Edwin van Teijlingen. Objectives. Students should be able to : Outline main sociological approaches to health & development in Third World Describe effect of economic inequality within & between countries on health Describe relationship poverty & health
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International Health Dr Edwin van Teijlingen
Objectives Students should be able to: • Outline main sociological approaches to health & development in Third World • Describe effect of economic inequality within & between countries on health • Describe relationship poverty & health • Describe importance disease prevention
Human Development Index Categories of development • Japan, Canada, USA, Australia, NZ and Western Europe as "developed" or industrialised regions, or ‘First World’. • South and Middle America, Africa and most of Asia are ‘developing’ countries or ‘Third World’ • Russia and Eastern European countries or ‘Second World’ are somewhere in between. • Some ‘developing’ countries are ‘Least developed’ (or Fourth World). • World Bank classifies by gross national income (GNI) per capita p/a: low-income (<$905); middle ($906 - $11,115); and high-income (more than $11,116).
Developing countries tends to: • Agriculture more important than manufacturing. • Limited specialisation and exchange. • Not enough savings to finance investment. • Population is expanding too rapidly for available resources. • A low standard of living.
Health in the Third World • Main causes of death: • HIV/AIDS • Maternal death (pregnancy & childbirth) • Tuberculosis (TB)
Less Developed / Developed • Overall (NB data quality problems) chronic and degenerative diseases associated with old age predominate in the West • Infectious and parasitic diseases (along with childbirth-related deaths) leading to more deaths at younger ages prevail in Third World.
Underlying causes • International Classification of Diseases (ICD) , Version 10 www.cdc.gov/nchs/data/icd9/draft_i10tabular.pdf • Z59.4, Z59.5 • Problems related to housing and economic circumstances – Lack of adequate food, Extreme poverty
Interrelated issues of development • Economic development/ Urbanization • International Relations/ Politics • Education • Birth rate, family planning, life expectancy • Health care
Politics! Bush withholds Money for U.N. Family Planning Fund “President Bush withheld $25 million in funding from the United Nations Population Fund on Friday in a move likely to appeal to opponents of abortion as he seeks re-election” Reuters 4/10/2004 http://www.worldrevolution.org/article/1541
Third World - Definition • Third World, Less Developed Countries (LDCs), the South, represents geographically, demographically, politically, culturally and economically diverse. • Who decides? What does it mean? E.g. in 2004 Cape Verde met the ‘qualifications’ for graduation from ‘least developed’ to ‘medium developed’ country
Not all equally poor I • LDCs are not equally poor, nor is this whole population in even the poorest country equally poor. • Indicators of development – Averages hide inequalities and inequities
Not all equally poor II • ‘Development ‘ unequal distribution of resources in North and South, also to unequal distribution within countries • OPEC countries such as Venezuala & Indonesia are different LDCs than e.g. Bangladesh & Malawi.
Rich people in poor countries • There are poor people in rich countries (e.g. homeless in UK) and very rich people in poor countries • BMW defies Dhaka’s potholes www.news.bbc.co.uk 24/07/03
2. Bangladesh Struggles to Cope(news.bbc.co.uk/1/hi/special_report/1999/06/99/world_population/382186.stm)
World Population Growth, 1750–2150 Source: United Nations, World Population Prospects, The 1998 Revision; and estimates by the Population Reference Bureau.
LDCs Population problems? • Population growth is high in many LDCs, whilst mortality rates are declining. • Estimated growth between 1988-2020 • Europe 0.3% • N. America 0.7% • Asia 1.9% • Africa 2.5% (Population Reference Bureau, Washington DC)
Population problems? • High % of population under 15. In Europe 20%, N.America 22%, Asia 34%, Africa 45% • At same time population is ageing, especially in middle classes • Sub Saharan Africa has shown fastest population growth over last four decades. Population will continue to grow despite reduction in life expectancy – HIV/AIDS epidemic • Changing populations – age distribution • Consequences?
Patterns of population change 2000 • Source: United Nations, World Population Prospects, The 1998 Revision.
World population • World population reached 6 billion in October 1999 • Will reach 7 billion in 10 years, if current rate maintained • Over 1 billion adolescents • Biggest group to make transition from childhood to adulthood
Population… • Population growth: more births than deaths • Two main reasons for this growth • Improvement of disease control through widespread improvements in health care, esp. public sanitation • Improvement in nutrition throughout the population A. Webster (1990) Introduction to the Sociology of Development (2nd Edition) London: Macmillan, p98-128.
Family Planning • Can population growth be contained? • Can we persuade the poor to have less children? • Policies of one child families • Incentives to have less children, longer time between each child, have first child later etc • ‘Forced’ steralisation – e.g. Peru, sterilisation quotas • Is population growth the problem?
Education & Age at first birth • In Sub Saharan Africa, half of girls with < seven years education will give birth before they are 18 years old • 1/5 of those with more education will give birth before 18 • In the USA, one third of girls with less than basic education will give birth before 18 • Only 1/20 of those with more education will do so
Teenage birth common: • > 10% of all births worldwide • > 14 million births/year Variation, e.g.: • < 1% of births in Japan • > 50% of births in parts of Africa
Improvement in education • Delay childbearing • Major impact on population growth • A woman who has first child by 18 will have 7 children • If she waits until her early 20s, she will have 5 or 6 • If waits until late 20s, will have 3 or 4
Why does population growth slow down? • Proximate variable (social, cultural & economic factors play a role) • Mechanisms of demographic transition (relates to general process of industrialisation) • Micro level explanations (generally critical of sets of theories above) Hewitt T & Smith I (1992) Is the world over populated? In: Allen T & Thomas A (Eds) Poverty & Development in the 1990s, Oxford University Press
Proximate variables • Proportion of people married • Contraceptive use • Prevalence of abortion • Post – birth infertility • Explanatory power of such a variable may not be great
Mechanisms of Demographic Transition Range of factors cause fertility to fall in process of industrialisation & development • Urbanization increases cost of raising children • Fall in production value of children (education/ labour laws/skilled labour) • Role of women & earning opportunities outwith household
What can be done? • Greater individual control over fertility decisions/contraception • Lower infant and childhood mortality • Availability welfare & insurance schemes
Micro-level Explanations • Explanations based on economic value of children which is high in societies with low social security for elderly. • Intergenerational wealth flows: • fertility is high where wealth flows from children to adults (e.g. child labour) • Fertility is low where wealth flows from adults to children (e.g. paying school fees)
Poverty Dhaka, Bangladesh in the wet season
Poverty and Famine • Much of poverty we know about from media, i.e. famine and (natural) disasters. • For many more Third World people poverty is chronic. The day-in-day-out hunger of not having enough to eat (i.e. calories, vitamins, minerals, etc.) which leads to malnutrition. This does not make world news, but it is estimated that it takes many more lives each year than the better publicized famines.
Being poor, becoming poor Poverty is not only a living condition of many people, but also a process. Households become poor or poorer by loss of assets. To meet big needs it is necessary to mortgage or sell capital assets, or go to loan sharks. Chambers refers to this as ‘poverty ratchet’. Chambers B (1983) Rural Development London
Poverty ratchet Five catalysts of poverty ratchets: 1. Social conventions: e.g. dowry, funerals; 2. Disasters: human made, fire, theft, etc.; 3. Physical incapacity: illness, childbearing, accidents; 4. Unproductive expenditure: gambling, bad luck in business; 5. Exploitation: excessive demands of powerful elite (bribes). Chambers B (1983) Rural Development London: Longman: 114-118
Out-of-pocket expenses for health care Formal/informal fees Transportation Supplies & equipment Childcare Greater consequence for poor Loans, high interest Sell assets Mortgage land or crops Loss in production/ household income Debt Example - Illness
Maternal Mortality • > 500,000 women die each year due to complications of pregnancy and childbirth • Every minute of everyday, at least one woman loses her life and 15 more endure long-term morbidity
Socio-economic consequences • “only the tip of the iceberg” (Koblinsky 1995) Koblinsky M A. Internat J Gyn & Obstet 1995; 48: S21-32. • Children up to age of ten are three to five times more likely to die within two years • Added economic hardship (poverty ratchet) • Education of existing children • Maternal morbidity – social exclusion
Maternal Mortality • Vast majority unpredictable, occurring around time of delivery • Vast majority preventable • ICD-10 definition “the death of a woman while pregnancy or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by pregnancy or its management but not from accidental or incidental causes” • BUT hard to measure, data hard to get
Determinants of maternal mortality Pregnancy Health status Reproductive status Complication Socioeconomic and cultural factors Access to health services Disability Health care behaviour/ use of health services Key Component factors Direction of influence Unknown or unpredicted factors (Adapted from: McCarthy & Maine 1992)
Maternity care • Many women have no access to either a trained midwife nor appropriate health care facilities • Many women deliver at home with family members or TBAs (Traditional Birth Attendants) • Estimated that around 15% of births require some intervention
International interventions • Safe Motherhood Initiative launched in 1987 to reduce maternal mortality by half by 2000 (little progress) • Millennium Development Goals (MDGs) – Reduce maternal mortality by 75% by 2015 • WHO moving away from training TBAs to recommending presence of someone with midwifery skills & access to hospital emergency care
Three Phases of Delay 1. Decision to seek care; 2. Reaching appropriate obstetric facility once decision has been made to go; 3. Receiving adequate and appropriate care once facility has been reached. Thaddeus S, Maine D. Social Science & Medicine; 38:1091-1110
TBA (Example India) Senior birth attendant is typically the mother-in-law (sas) The dai—even though called in 90% of births—is not regarded as a midwife in the Western sense, being low-status, low-caste menial. The dai is called late in labour, she has demeaning tasks of internal examination and otherwise provide information about labor to the mother-in-law. Payment emphasizes their inferiority. Fee negotiations can be abusive & payment not always fulfilled. The typical dai is landless, illiterate, widowed older female who cannot support her children, and is untrained in midwifery. Jeffery, R. & Jeffery, P. (1993), “Traditional birth attendants in rural north India”, in S. Lindenbaum & M. Lock (eds.), Knowledge, Power & Practice Berkeley: Univ. California Press, pp.7-31.
HIV/AIDS GLOBAL SUMMARY 2004 • 39.4 million (35.9-44.3) living with HIV • 4.9 million (4.3-6.4) newly infected with HIV in 2004 • 3.1 million (2.8-3.5) AIDS deaths in 2004
Economic Impact During the 1980s the economic recession hit most of Africa. In terms of average income per capita “Twenty-four countries in sub-Saharan Africa were worse off …at the end of the 1980s than at the beginning of the decade” [Jespersen 1990]. The economic recession forced governments to cut their spending on public goods such as health and education at a time when the need for provisions for a growing number of infected people as well as measures to prevent further spread of HIV would have required an increase in funding for both health care and education. Jespersen E, 1990 Household responses to the economic crisis and its impact on social services in the 1980s. Unicef. (unpublished) Quoted in: Sanders D, Sambo A, 1991, AIDS in Africa: the implications of economic recession and structural adjustment. Health Policy & Planning, 6:164
HIV/AIDS in Africa (quality of data) Official AIDS figures are notoriously for being underreported. The much larger number of people with HIV (most of whom don’t show signs of being ill) can only be estimated from limited (in time and/or place) population samples. Thus estimates of total incidence &prevalence in a population have to be drawn from incomplete information from selected populations.
HIV/AIDS: explaining poor data Tanzania - low reporting can be partly explained through poverty, costs of HIV tests, the unfavourable conditions for transport, storage and supervision all conspire to make HIV testing less accurate in the small rural hospitals. Moreover, the priority in small hospitals is likely to ensure safe blood supply as supposed to diagnosing infection or producing scientific data [Nicoll & Brown 1994:27]. Nicoll A, Brown P, 1994, HIV: beyond reasonable doubt. New Scientist (15 Jan.):24-8
Women and AIDS • AIDS is affecting women most severely in places where heterosexual sex is a dominant mode of HIV transmission • Adult women in sub-Saharan Africa are up to 1.3 times more likely to be infected with HIV than male counterparts • Young women aged 15-24 years, 3 times more likely • Variation across countries
Women and AIDS… • Social norms impose a dangerous ignorance on girls and young women • Many risks embedded in social relations and economic realities • Prevention activities need to take into account gender and socioeconomic inequalities • Alongside other efforts to ensure basic human rights – e.g. violence, reproductive health, education, property rights