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Seminar on Macro-Meso-Micro Influences on Health, Changing Patterns of Morbidity and Mortality

Yaoundé, Cameroon, June 5-8, 2002
Organised by the IUSSP Committee on Anthropological Demography

Report

The aim of the seminar was to examine health and health-seeking behavior from the perspective of the political economy of native populations, local communities, nation-states, and international organizations. The seminar aimed to foster the applications of qualitative methodologies to the multilevel analyses of the effects of globalization, financial crises, and economic restructuring on inequalities in morbidity and mortality risks among individuals, families and communities.

"Globalization" has many definitions. So as not to constrain contributors excessively, no single definition is insisted upon. The notion includes, however, not simply international flows of capital but of people, information, political influence and infectious agents as well. "Financial crises" refers to the economic turmoil that has afflicted countries in various parts of the world in the 1990s, most notably those in Southeast Asia and the former U.S.S.R. "Economic restructuring," also known as "economic stabilization" and "structural adjustment programs" (SAPs) refers to a series of policy interventions designed by major lenders such as the World Bank and the IMF, which have been carried out over the last 15 years or so primarily in developing countries and Eastern Europe.

The consequences of globalization, economic crises, and structural adjustment have been the subjects of intense debate and criticism, but the evidence regarding their impact on health services, health status, and health care utilization remains scattered and uncertain. The pessimists contend that: 1) The pace of mortality decline achieved in many developing countries following World War II is unlikely to be sustained owing to the slow pace of economic development and of social and health infrastructures, especially in rural areas where the overwhelming majority of the population lives under sub-standard conditions; 2) Socio-political unrest, ethnic tensions and civil wars are likely to undermine the effectiveness of particular health interventions, especially those for the most vulnerable segments of the populations living in underserved rural areas and ghetto milieu of towns, and to engender difficulties in organizing broad community-based primary health care systems consistent with the Alma Ata Declaration and the Bamako Initiative; and 3) Recent developments in disease patterns and drug resistance (e.g., the spread of chloroquine-resistant malaria) coupled with the AIDS epidemic are likely to have a deleterious effect on co-morbid states and survival prospects. The dispersion of HIV infection has shown how permeable the world is to the dissemination of pathogens.

On the other hand, optimists argue that the secular trend of life expectancy everywhere has been upward, even when the pace has differed; that reversals have been rare and temporary; and that there is no reason to think that human ingenuity will be incapable of successfully solving the problems resulting from continued economic expansion in the future as it has in the past. The seminar papers were meant to address these issues using case studies from various parts of the world.

Session 1

Linda Whiteford: Idioms of Hope, Idioms of Despair: Health Resilience in Times of Structural Adjustment

This paper described personal experiences within a political/economic analysis by incorporating community voices in an analysis of the health consequences of structural adjustment polices (SAPs). The "idioms of hope and despair" refer to the terms used in some communities in the Caribbean to describe the relationship between them and their government. Using data from several Caribbean countries, this paper brought into focus the macro-level economic policies and programs, the national level economic and political responses, and the personal experiences of people living in communities most effected by those changes. During the decade of the 1980s, the economic crisis in the Caribbean was intensified through a series of international economic restructuring policies initiated by the World Bank, along with the crisis in sugar production and the aftermath of the OPEC oil embargo. These events led national governments to eviscerate their social service programs, including the provision of public health necessities. Levels of infectious disease rose, followed by increased levels of malnutrition. To understand how people respond to such changes in their lives, this paper embeds the words and expressions of communities under siege in the context of global economic trends. The result is a complex, multi-tiered analysis or the social production of health in times of crisis.

Charles L. Briggs and Clara Mantini-Briggs; Our Children Die as the Boats Pass Us By; Petroleum Exploitation, Health, and Social Inequality in Eastern Venezuela

Along with "the Yanomami" of the southern state of Amazonas, the population of fluvial area of Delta Amacuro State on the eastern periphery of Venezuela faces some of the most appalling health conditions in the world. A recent survey revealed 36 percent infant mortality, and some 50 percent of children die before reaching puberty. Approximately 60 of the population is infected with tuberculosis, with 3 percent of young children exhibiting symptoms of tuberculosis-apparently the highest rate in the world. Cholera, malaria, and dengue complicate the picture even further.

In the face of a prolonged economic crisis and the location of some 80 percent of the country's population in poverty, Venezuela once again invited transnational oil companies into the national space in the 1990s. At the same time that this reversal of the 1970s nationalization of the oil industry has brought technology, foreign workers, and development funds into lands occupied by what anthropologists have identified as a classic pre-modern Amerindian society, a profound economic crisis has pushed the residents of other delta areas back into the forest, greatly curtailing their ability to participate in the national economy, engage in civil and political processes, and obtain government services. Oil companies have dedicated millions of dollars to providing basic services to nearby communities, funding studies of health, economic, and social conditions, and creating projects in education, health, and economic development.

Here we have a classic case study in globalization. On the one hand, major transnational corporations have brought tremendous capital investment and high technology to an area in which some people still live as hunters-fishermen and gatherers. Oil companies have provided residents of communities located within "oil blocks," the areas to which they obtained exploration and production rights, with clinics, medicines, and the services of qualified physicians and nurses. Serious cases are sometimes air-lifted to urban hospitals in the same helicopters that bring workers to oil camps. At the same time, residents who live just beyond the borders of "oil blocks" watch family members die as boats transporting medical personnel and supplies pass in front of their communities.

This paper examines this exceedingly rapid globalization process in terms of its effects on morbidity and mortality. Our focus is on the broad range of ways in which the massive infusions of workers, technology, capital, and political-economic interests associated with petroleum exploration and exploitation shape health conditions. Two processes are identified as crucial. First, globalization is less usefully characterized as a "flow" of capital, goods, culture, information, and people across borders or as the eclipse of the nation-state than as a process that transforms institutions within countries in ways that render them useful to transnational capital. Even governmental agencies that bear no direct relationship to global markets, such as legal, penal, medical, and public assistance agencies, are often forced to make radical and abrupt changes. One focus is thus on how these transformations of state and parastatal ideologies and practices shape health outcomes.

Second, some investigators suggest that health outcomes correlate most closely with social inequality, not poverty per se. This paper examined the effects of rapid and dramatic increases in social inequality between adjacent communities in terms of their health effects, employing both quantitative and ethnographic techniques.

Session 2

Lisa Ann Richey, From the Policies to the Clinics: Population and Women's Reproductive Health in Tanzania

The post-Cairo agenda of "women's reproductive health" expands the scope of population interventions to embrace a wide array of concerns centered on reducing the morbidity and mortality of Third World women and their children. This eclectic agenda has been heralded as a step forward, moving beyond the narrow depictions of a population problem that can be solved by contraception. However, the relationship between fertility limitation and improved women's and children's health is complex, and may not always be complementary given the realities of the post-adjustment health care system in most African countries. The public health sector, debilitated by both economic crises and their solutions, presents rather formidable obstacles to successful implementation of a reproductive health agenda. Using a case study of Tanzania, this paper examined the links between the global population discourse, national health policy and the realities that confront women who seek services in local clinics. In Tanzania, population control has been an important part of the bundle of recommendations given under the rubric of structural adjustment. The resulting retreat of the Tanzanian state from the health sector, coupled with an upsurge in donor interest in population, has led to a public health care system equipped primarily to supply contraceptives. I argue that we need to look beyond the rhetoric of Cairo to examine health-care priorities as they are implemented in local clinics and perceived by the women who seek care for themselves and their children.

Elisha P. Renne: Hajera at the Hospital: Changing Patterns of Child Morbidity and Access to Health Care in a Northern Nigerian Town

In January 1995, a two-year-old girl named Hajera, who could not walk, was taken to a nearby university hospital, in Zaria, Northern Nigeria. After many tests and much expense, she was diagnosed as being malnourished. Hajera began to walk after a month of being fed a protein-rich diet. This seemingly simple solution to one child's health problem is belied by the enormous difficulties many parents face when seeking health care in contemporary Nigeria. Theoretically, they have several options for treating their children when sick. They may attend either of two large general hospitals in Zaria or one of the many privately-run clinics. They may also opt to self-treat, based on the advice of local chemists, traditional herbalists, or experienced older women, often relations living nearby. In practice, their actions may be constrained by a lack of cash, transport options, cultural practices (e.g., seclusion), religious beliefs, education as well as by personal preferences and experience. Furthermore, these micro-local choices and constraints have been affected by the uncertain political economic situation at the national level in the 1990s, reflected in the annulment of the 1993 Nigerian presidential election and continually changing political leadership (there have been five heads of state from 1993-1999). The political unrest of this period contributed to frequent labor stoppages, both in hospital and in transport services. This situation exacerbated an already declining public health care system, undermined by economic restructuring introduced in the mid-1980s, associated with IMF loan rescheduling that included health policy changes such as the reduction of funds for public health care facilities and the introduction of user fees.

This paper considered the interconnections between these three levels of health-related practices and policies, focussing on the health consequences for a group of children, whose families reside in one area of Zaria, served by a major university teaching hospital that was severely affected by these national and international programs. Findings are based on a case history of one child, Hajera (from 1994-2001), on interviews of 100 married Hausa Muslim women with children living in Zaria City (in 1994, 1996, and 2001), on hospital pediatric data (1996-2001), on interviews with Zaria Local Government Health Department officials (2001), and on contemporary newspaper reports. Using qualitative and quantitative materials spanning a seven year period, this paper assessed changing patterns of child morbidity and access to health care which have resulted from public health restructuring and related socioeconomic and political changes in one Northern Nigerian town.

Session 3

Meredeth Turshen: War and Public Health

Contemporary African conflicts stretch from Algeria to KwaZulu Natal, from Casamance to Mogadishu; some have lasted thirty or forty years and have displaced millions of people (half the country's population in the cases of Liberia, Rwanda and Somalia). We know that the major population movements experienced by war-torn societies create huge refugee crises and public health problems ranging from environmental hazards to disease epidemics. We lack details on much besides the AIDS crisis. We suspect that war-torn societies experience dramatic demographic changes in both the size and structure of populations, but assessments, which are needed for accurate planning, are rarely made. Conflicting estimates of mortality and morbidity are part of the propaganda of warring sides.

It has been argued that the main development agencies and international powers are using the concept of 'post-conflict' as an excuse to devote fewer resources to the amelioration of complex political emergencies in the third world and to allow structural adjustment policies to reign as usual. The agencies are labelling war as peace so as to justify implementing shock therapy to create the market cure for war.

Many states emerge from these conflicts weakened and bankrupt, unable to respond to populations disabled by fighting, crippled by landmines, bedridden by malaria, and faced with an uncontrollable epidemic of AIDS. Yet international donors persist in supporting the micro-projects of nongovernmental organizations, which is to say the private health sector, instead of rebuilding state services. The result is not only increasing inequality between those who can afford to pay private fees and those who cannot, but also the growing neglect of public health, which is beyond the reach of NGOs. Case studies of Uganda and Rwanda describe the ramifications of the continued application of structural adjustment programs for health status in war-torn societies.

Albert-Eneas Gakusi and Michel Garenne: Political Regimes and Infant mortality in Rwanda : from 1900 to 1992

The economic and socio-political context of Rwanda is analyzed, to put in perspective the changes in social and health conditions in the 20th century. In this country, the political changes seem to have played an important role in the evolution of the public investments, notably in health services.

During the colonial period, it is mainly the Christian missions - in support of the colonial authority - that took care of the health and of the education of the children. We find moreover a strong correlation between the number of converts to Christianity, the use of health care and schooling. After 1945, we note a significant improvement of health indicators, with the disappearance of the major famines, the availability of antibiotics, the increase of the health staff and of the sanitary infrastructure, which induced a decline in mortality, especially for children.

The transition towards independence proclaimed on July 1, 1962, was marked by a period of socio-political upheavals, associated with the so called "Hutu Revolution" of November, 1959, which resulted in the end of the monarchy and Tutsi rule. The years following independence were characterized by numerous difficulties, having to do with the creation of new institutions, the introduction of a new administrative framework, and the transfer of public services from Bujumbura to Kigali (until then Bujumbura was the administrative core of the Trusteeship Territory of Rwanda-Urundi). Compounding these difficulties, most Belgian administrators went home while hundreds of Tutsi with valuable skills in the health, education and agricultural sectors, were driven into exile. Other problems cropped up: chronic insecurity in the border areas due to armed raids by Tutsi, the extreme weakness of the economy and dearth of financial resources, niggardly assistance from foreign donors, all of which help explain rising rates of infant mortality in the post-independence years.

However, the government of President Kayibanda took important steps towards promoting development, including the opening of the National University of Rwanda, where the training of doctors occupied a dominant place. In spite of its efforts to speed up economic and social modernization and concern with fair distribution of the economic resources, the first Republic was characterized by stagnation of economic indicators and degradation of social indicators. Its pluralistic political system ended in a monoparty system and internal rivalry within the "Mouvement Démocratique Républicain-Parti du Mouvement de l'Emancipation Hutu (MDR-Parmehutu)".

The 1973 coup by Major General Habyarimana brought an end to political and ethnic conflicts and brought into existence a new power arrangement. The period from 1973 till 1990 was peaceful. The second Republic benefited from investments made since independence, notably in qualified personnel and in infrastructures. It strengthened the actions begun in the medical, educational and economic sectors. It received a substantial international aid. The economic indicators improved until the beginning of the 80s when the country witnessed a decline of its living standards. The political system set up by Habyarimana was disputed from 1989 on, and a war was engaged in October, 1990, which evolved in the genocide of 1994. Meanwhile, the medical coverage had considerably improved. While in 1963 there was one doctor per 135 000 inhabitants, in 1986, there was one per 25 000. The decline of the children mortality between 1977 and 1992 can be explained by this new context.

Session 4: Local presentations

Professor Rose Leke and Dr. Roger Moyou each gave presentations on various aspects of malaria in Cameroon.

Session 5

Rakotondrabe Faraniaina Patricia, a student at the University of Yaounde, presented her work.

Session 6

Robert Leke and Barthelemy Kuate-Defo, presented the results of their work on maternal care in Yaounde.

Khama O. Rogo, Davidson R. Gwatkin , John F. May , A. Edward Elmendorf, Manju Rani, and Agnes Soucat: Health, Nutrition, and Population Equity and Outcomes in Sub-Saharan Africa: Implications for HNP Strategies and Engagement of African Researchers.

The authors reviewed differences in health, nutrition, and population (HNP) outcomes, levels and trends, in different poor-rich quintiles from secondary analysis of Demographic and Health Survey (DHS) and other household data sets. The analysis was based on an asset index. Data under three HNP indicators (antenatal care, skilled attendance at delivery, and infant mortality) were explored. Regional comparisons of Africa, South Asia, and Latin America are complemented by inter-country analysis of 22 African countries. The paper then showed how newly available data sets may be used in the analysis of health equity and outcomes, at the country level, with case studies of Kenya and Burkina Faso. The paper discussed new international initiatives for health equity and the use of the Millennium Development Goals adopted by the United Nations as a framework for the strategic options of the World Bank for its work on health, nutrition and population in Africa. It finds that strengthening African health researchers, and engaging them increasingly effectively in the analysis of newly available household data sets, is a key to further analysis and policy work on health equity in Africa. In addition, the paper raised the critical issue of the value of the findings in initiating action to address health equities and adverse outcomes in the developing world. In this specific regard, is there value in addressing the gaps and how can donors, governments and health providers join forces to ensure that resources meant for the poor, reach the poor?

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