15 Health & Development, Poorer Countries: Nepal

1. 15 Health & Development, Poorer Countries: Nepal

2. Learning Objectives • Identify factors known to be associated with health outcomes in poor countries • Describe possible theories for why countries end up with the health they do? • Critique the concept of development used in reference to stages for countries

3. Who has traveled to poor countries: • Who has traveled to a poor country?

4. Who has traveled to poor countries: • Who has traveled to a poor country? • Who has lived in a poor country?

5. Who has traveled to poor countries: • Who has traveled to a poor country? • Who has lived in a poor country? • Experiences? • Impression of health status of people there?

6. HUMAN HISTORY • Descended from other primates, unclear just where we branched off • Million year human history, give or take a few hundred thousand years • Terms • Hunter-gatherers, forager hunters mobile (bands) • Prehistory: paleolithic, mesolithic (transition) • Neolithic (cultural systems based on domesticated plants, animals) • tribes

7. gatherer-hunters or forager-hunters for 99% of human existence • lived in small groups of 20-75 • spent most of the time in leisure pursuits in small, close-knit groups called bands • very little hierarchy, vigilant sharing • very difficult to conquer or enslave, but could be driven out or killed • can take their territory but not their stored resources • any human evolutionary changes resulting from genetic drift had to have occurred during this time

8. Societies from the Paleolithic to Present • Forager-Hunter society has been human’s most successful adaptation • “Cultural man has been on earth for some 2,000,000 years; for over 99% of this period he has lived as a hunter-gatherer. Only in the last 10,000 years has man begun to domesticate plants and animals..... Homo sapiens assumed an essential modern form at least 50,000 years before he managed to do anything about improving his means of production.... To date, the hunting way of life has been the most successful and persistent adaptation man has ever achieved.” • Lee, R. B. and DeVote I. (1968). Man The Hunter.

9. Poverty from the PALEOLITHIC to PRESENT • The world's most primitive people have few possessions, but they are not poor. Poverty is not a certain small amount of goods, nor is it just a relation between means and ends; above all it is a relation between people. Poverty is a social status. As such it is an invention of civilization. It has grown with civilization [as an invidious distinction between classes] • Marshall Sahlins Stone Age Economics

10. Egalitarianism in Human Societies • Egalitarianism product of human intentionality • “if tendencies to hierarchy are to remain decisively reversed, both hunter-gatherers and people living in modern democracies must consciously create, and carefully enforce egalitarian plans or blueprints” • Boehm: Hierarchy in the Forest • Antiauthoritarian Sanctions • Moderate: criticism, ridicule or disobedience • Strong: ostracism, expulsion, deposition, desertion • Ultimate: execution • Gender egalitarian

11. Egalitarianism (natural selection) • Large forebrain needed for social skills and political intelligence • Intuitive actuarial intelligence (or insurance program) • meat in large quantities is always shared (reduces family-level variance in protein intake, band-wide sharing, cooperative systems) • Morality, egalitarianism, warfare • White sclerae • Gossiping the functional equivalent of primate grooming • Group Selection of altruistic traits (altruistic genes) • Competes with within-group selection of selfish traits • Nepotism vs altruism (vigilant sharing socially enforced) • Loss of total body erectile hair capability (weapons) • We go to war is evidence of altruistic traits

12. Agricultural Societies • Emerged to cope with increasing population and decreasing food supplies from foraging • Inventions, technologies,and organization related to agriculture usually known to societies • These technologies only adopted when necessary and adoption goes hand in hand with social stratification (Ester Boserup) • Less work before present "English data on farm work in the Middle Ages show that at least in England the working days which the peasants had to perform for the landlords lasted from sunrise to noon only. A fair day's work seems to have been a half-day's work."

14. Agricultural Societies • Anthropological studies suggest that primitive peoples usually consider both hunting, fishing and food collection as pleasurable activities, while food production is resorted to only to the extent that other and more agreeable activities fail to provide sufficient food. The effort devoted to food production is often seen to be limited to the bare minimum of hours necessary to avoid starvation. (Boserup)

15. Agricultural Societies • Expansive: settlement patterns changed from bands to tribes, chiefdoms, states • Destroyed hunter-gatherer societies: • Mostly through behavioral violence • Bounties in USA: (£ 20 for male £ 10 for a female or child) • More recently through ethnocide • Cultural: Residential Schools • Brody’s The Other Side of Eden • Today: destruction using structural violence via globalization but older methods of forced resettlement still used (Kalahari Bushmen)

16. Agriculture villages: of several hundred to few thousand, sharing common language, culture, linked in loose confederacies (tribes), or united more formally in rank societies or chiefdoms comprising many thousands • safety in numbers because stored food in towns • craft specialization emerges, so proximity improves efficiency of specialized tasks • farmed and stored foods become private property • central government control more possible civilization: communities of varying sizes, integrated into states Importance of POWER and power relationships

17. Agriculture • fertility increases because • availability of weaning foods • child labor utilized in farming economies • child rearing did not require as much investment since they could be put to work earlier in life • reduced strain on women carrying children • more difficult to be mobile mother • increased mortality • 30 fold population increase over 4000 years

18. Agriculture hierarchies emerged as larger and denser societies replaced smaller societies in pre-history Knauft graph internal stratification within individual societies inequality of power & exchange between societies began 5000 years ago DIVISIONS ruler / ruled rich / poor literate / illiterate townspeople / peasants

19. Knauft graph

20. Agriculture • infectious diseases increase • TB a disease of crowded urban poor and ghettoes and reservations • bubonic plague • influenza and cholera with international military operations • AIDS • contemporary forager-hunters display low rates of • infantile and other diarrhea, anemia • epidemic diseases • only have chronic diseases and some zoonotic and soil borne diseases which don’t depend on people for survival and transmission

23. Health Declined with agriculture • “Agriculture has long been regarded as an improvement in the human condition: Once Homo sapiens made the transition from foraging to farming in the Neolithic, health and nutrition improved, longevity increased, and work load declined. Recent study of archaeological human remains worldwide by biological anthropologists has shown this characterization of the shift from hunting and gathering to agriculture to be incorrect. Contrary to earlier models, the adoption of agriculture involved an overall decline in oral and general health.” (Larsen, C. S. (1995). "Biological changes in human populations with agriculture." Annual Review of Anthropology)

24. 8 0 7 0 6 0 5 0 4 0 S u b - S a h a r a 3 0 2 0 J a p a n Life Expectancy Trends: Paleolithic On U S A R u s s i a P a l e o l i t h i c n A f r i c a R o m e 1 0 0 , 0 0 0 ( 1 9 9 0 ) 1 0 0 0 0 ( 1 9 0 0 ) 1 0 0 0 P r e s e n t Y e a r s b e f o r e p r e s e n t ( l o g s c a l e )

25. Population Health Measures in History • life expectancy estimates lie in range of 20 to 50 years until the last century • 25 years is estimate for • Europe in 18th & early 19th century • urban Europe well into the 19th century • Japan had higher life expectancy than W. Europe 19th century • Italy, Spain, Hungary it was below 30 for most of 19th century • US no data on life expectancy before 1900 but suspect higher than Europe (less hierarchy then) • better than India prior to 1920

26. Hundreds of years ago:Life Expectancy increased after childhood

27. Leigh & Jencks 2007

28. GLOBAL HEALTH Theories: • Living standards improvements (Preston) • Sanitation • technical improvements preventing early death? • Nutrition (Fogel, McKeown (medical treatment played minor role) • Social factors (Caldwell in 1980s), female education • Psychosocial factors • Qualitative changes • Biological changes • Treatment of early life • Culture?

29. Leigh & Jencks 2007

30. Europe after 1900psychosocial changes • Better standards of treating children

31. childhood • "The history of childhood is a nightmare from which we have only recently begun to awaken. The further back in history one goes the lower the level of child care, and the more likely children are to be killed, abandoned, beaten, terrorized and sexually abused." • DeMause The History of Childhood 1974

32. Europe after 1900psychosocial changes • Better standards of treating children • Societies less repressive • Fewer public hangings • Less cruelty to animals • Softening quality of social relations • Decreasing reliance on threat or fear as basis of social order • Growth of democracy, equality before law • Development of welfare state

33. Murray and Chen 1993: theory • 3 inter-dependent factors at work: • Level and distribution of national income • Effectiveness of public policies • Efficiency and effectiveness of public policies toward mortality control

35. Terminology Most of the world (them) Third world Less developed countries Less industrialized countries Majority countries Majority world Former colonies Exploited countries Underdeveloped countries Developing countries South Us First world Developed countries Industrialized countries Minority countries Minority world Colonizing countries Imperialist countries Overdeveloped countries North

36. Changes after 1950development • "Late development" Ron Dore • Poorer, less developed nations learn from our mistakes • "development" a charged valued driven word • Different meaning than "child development" • or "plant development" which are natural processes Nothing natural about 'development' in reference to natural process for a nation or society

37. QUIZone country has TWICE the child mortality of the other • Sri Lanka or Turkey? • Poland or South Korea? • Malaysia or Russia? • US or Sweden? • Pakistan or Vietnam? • Thailand or South Africa?

38. QUIZone country has TWICE the child mortality of the other • Sri Lanka or Turkey? • Poland or South Korea? • Malaysia or Russia? • US or Sweden? • Pakistan or Vietnam? • Thailand or South Africa?

39. Making Transition Work for Everyone: Poverty and Inequality in Europe and Central Asia, World Bank 2001

40. GLOBAL HEALTH 2004/06 Gap 51 years 1990/93 Gap 37

42. Factors influencing global health today

43. National Health Determinants • Where countries were in the health olympics starting blocks

44. National Health Determinants • Where countries were in the health olympics starting blocks • Colonial history 3 types: • 1 few Europeans settled (PEASANT COLONIES) • societies were peasant colonies with Europeans as administrators or tax collectors or exploiters • plantations dominated economy in some places • Europeans didn't stay in power after independence • Outcomes depended on how much Europeans helped local elites to plunder • India, Nigeria, Sri Lanka

45. National Health DeterminantsWhere countries were in the health olympics starting blocks • Colonial history: • 2 Europeans settled as a minority (SETTLER COLONIES) • Tended to expropriate land and resources • Used indigenous peoples labor, imported slaves • Plantations, mining in Americas • Locals often not allowed to own land • After independence Europeans remained in power • Colonial system prevailed with elite exploitation

46. National Health DeterminantsWhere countries were in the health olympics starting blocks • Colonial history: • 3 Europeans settled as a majority (NEW EUROPE COLONIES) • Wiped out local peoples • Adopted systems similar to homeland Europe • Where there was more slavery, there was a greater hierarchy and worse health outcomes

47. Health Determinants of nationsWhere countries were in the health olympics starting blocks • How well they provided basic needs (food) • How much they support early life • How much they support ALL (social welfare systems) • Sense of community, social capital • Culture, values, ethos • Political systems: especially redistributive policies • "educated, capable, and demanding public"(Caldwell 1986) • Economic growth (up to ~1850 ↑living standards), then whether rapid & shared or not, if not shared, can worsen health • Hierarchy details: economic, social • Access to health care • Public health programs

48. Health Determinants of nationsWhere countries were in the health olympics starting blocks • How well they provided basic needs (food) • How much they support early life • How much they support ALL (social welfare systems) • Sense of community, social capital • Culture, values, ethos • Political systems: especially redistributive policies • "educated, capable, and demanding public" • Economic growth (up to ~1850 ↑living standards), then whether rapid & shared or not, if not shared, can worsen health • Hierarchy details: economic, social • Access to health care, Public health programs

49. Health - Growth or GNP/capita • Up to about $5000/capita GNP, further increases are associated with better population health • After about $5000/capita GNP, there is little gain associated with further economic growth

50. Deaton2003