Beyond Child Survival

Beyond Child Survival: Anthropology and International Health in the 1990s Mark Nichter; Carl Kendall Medical Anthropology Quarterly, New Series, Vol. 5, No. 3, Contemporary Issues of Anthropology in International Health. (Sep., 1991), pp. 195-203. Stable URL: http://links.jstor.org/sici?sici=0745-5194%28199109%292%3A5%3A3%3C195%3ABCSAAI%3E2.0.CO%3B2-G Medical Anthropology Quarterly is currently published by American Anthropological Association.

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MARKNICHTER Department of Anthropology University of Arizona, Tucson CARI,KENDAI~L Department of International Health Johns Hopkins School of Hygiene and Public Health

Beyond Child Survival: Anthropology and International Health in the 1990s Editor's Note: Two yeerrs ago I .sur~,eyedthe mntlu.sc~ript.ssubmitted to and uc,c,epted by this ,jourtzul crc,c,ording to ,field ~ ~ i t h imedic~rl tz anthropology and found that crpplied manu.sc~ript.sin it~tertzntionulhealth had u low repre.srntutiotl anlotlg .submi.s.siot~.sand practic,ally tlotle anlong uc.ceptutzc.es. To remedy this situution, I upprouc.hed Murk Nic.hter to put together ern issue on this su4jec.t to itlc.lude sotne of the best work in t l ? ~ asked Carl Ken~lc~ll ro assist him in the job, and ,field. He subs~~yuet~tly now, almost two yPurS luter, their jointly edited isslre comes to fruitioti.

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nthropology's role in international health has become increasingly visible in the last decade. This is in part the result of anthropology's return to a proactive stance in health and development and in part a response to new opportunities afforded by international health initiatives requiring social science input. The anthropological literature on international health has been dominated by studies of nutrition-related behavior and breastfeeding; fertility behavior and family planning; diarrheal disease, acute respiratory illness, malaria, and AIDS; technical fixes to health problems, such as oral rehydration therapy and imniunization; health care seeking and pharmaceutical behavior; and primary health care programs, strategies, and goals. While applied studies have focused on disease and on improving interventions and education as a means to achieving diseasespecific ends, other studies have adopted a critical and distancing stance, offering macroeconomic and macrosocial themes. such as the body dominated in medicine, new units of analysis beyond the individual and the community, new relativist and subjectivist methodological postures, and a concern with power and regional. national, and international linkages in the world economic system. Several review articles and recent books on medical anthropology have summarized this literature (Brownlee 1989; Coreil and Mull 1990; Heggenhougen and Shore 1986; Hill 199 1 ; lnhorn and Brown 1990; Johnson and Sargent 1990; Kendall

1990; Nichter 1989a. 1989b; Pillsbury 1989; van der Geest and Whyte 1988; Weiss 1988). Studies that identify a middle ground between macrosociological issues and the practical contexts of local life have been less well developed, even though this middle ground could draw on traditional anthropological themes. Largely missing in the literature have been studies that tie medical anthropology to research on the niicroeconomics of resource and time allocation in unplanned and planned change: the household as a social field of implicit contracts organized around activity sets, competing gender and generation demands, and power relations; and changes in consumer behavior and their social ramifications. Too little appreciated as well have been the institutional features of modernity. These include the conditions that have caused the demographic and epidemiological transitions. such as rapid urbanization, changing agricultural practices, and ecological change at both the micro and macro levels. Also, in an international health setting in which "body counts" and extrapolated statistics carry immense weight in health and development planning, anthropologists have not been vocal enough in questioning the meaning of existing statistics and helping to construct more appropriate indicators of i l l health in the context of what amounts to a high stakes zerosum game. This collection of four articles is a sample of approaches from this "middle ground" that attempts to address the potential for a bridge between applied, community-based studies and several of the themes discussed above. The article by Marilyn Nations and Mara Amaral calls attention to the quality of quantitative data used in health statistics and suggests that by utilizing local participants as death reporters, researchers may collect more accurate local level data on infant mortality. Nations and Amaral point out that at issue is not just the number of deaths but rather the collection of accurate records which affect both the allocation of resources on the basis of need, as defined by development agencies and ministries of health, and the evaluation of programs, which requires good baseline data against which to measure postintervention difference. In both cases, baseline data are required that identify which households are at greater risk for mortalitylmorbidity. Nations and Amaral note that the collection of descriptive epidemiological data is not neutral but politically motivated. Indeed, the c d ~ ~ e c tion of better mortality data constitutes a form of community empowerment in the context of poverty, where inaccurate numbers and caveats about inaccuracy serve to divert attention from policy issues. The authors suggest that the collection of data presenting a vivid description of poverty constitutes a weapon of the weak (Scott 1985). Another issue raised in this article involves the importance of looking beyond sickness and death to identify the sufferer. Within international health the theme has considerable practical importance. Not only does it inform us about the emotional investment parents have in children and the cultural coping strategies employed to mitigate loss, it raises questions about the ongoing health behavior within households that have experienced a child's death. For example, a study in the Philippines (Nichter) revealed two patterns of health behavior among parents of children who had died of diarrhea-or acute respiratory illness. ~ m o n gone group of impoverished villagers future health care response was faster and more prudent. Among a second group, however, parents were less willing to invest scarce resources in children, because their previous investment in a child who

ultimately died had not paid off. These villagers adopted a "wait and see" attitude. Little data exist on the impact of death and illness on health care decision niaking through time; such data would require understanding a continuous flow of conduct rather than a sequence of discrete acts of choice and planning. Three larger issues pertaining to quantification may be noted. First, anthropologists need to raise questions not only about the validity of data presented but the choice of indicators used in developmental planning. Millard (1991) has, for example, questioned the utility of infant mortality as the primary measure of health status in Third World countries. She argues for the use of child death data, suggesting that measures of infants saved do-not accurately represent sustained health and developn~ent.Her argument may be linked to Chen's characterization of child survival as involving chronic i l l health problems, not just the prevention and better management of acute medical problems (Chen 1986). This argument applies in India, for example. where a decline in infant mortality is complemented by a steep rise in child mortality. This issue is even more crucial in a post-healthtransition era when niorbiditv becomes the focus for health. Bevond child survival lies an integrated set of issues about c h ~ l ddevelopment (Super and Harkness 1986). The second issue is the practice of aggregating data across groups and localities which should be viewed separately, not lumped together for planning purposes. This issue also addresses the use of ambiguous categories such as urban1 rural, lower classimiddle class, and constructions such as "household inconie." which designates a specific sum but ignores the dynamics of intrahousehold resource allocation. The aggregation of health-related data from different regions and types of households may mask serious problenis and. when done intentionally, constitutes a form of political manipulation. The third issue relates to the meaning of health-related data and the trustworthiness of cross-regional or transnational comparisons. This issue is raised in Nichter and Cartwright's article on smoking. Members of a team of researchers studying smoking behavior in the southwestern United States (Teen Lifestyle Project, University of Arizona) have identified several categories of smokers, distinct in terms of consumption contexts, self-image. social interaction, psychological satisfaction, co-occurring behaviors such as drinking or dieting, and perceptions of what constitutes a habit and one's relative willpower and control. The number of cigarettes smoked by "smokers" varied across these contexts. When scrutinizing the plethora of data on global smoking, it is hard to get a sense of what kind of smokers are being described by national statistics. In Kiribati smoking prevalence among both women and men is exceedingly high, but one cigarette may be smoked over several hours (Alex Brewis, personal conimunication). Comparing this prevalence data to smoking among the Japanese or Javanese may be misleading. These indicators need to be improved and need to be contextualized. The range of behaviors must be delineated before indicators can be constructed. Ambiguous categories may obscure as niuch as they reveal. Coreil's article draws our attention to maternal time allocation. substitute child care provisions and the household production of health (Bennan, Kendall, and Bhattacharyya 1988). Her contribution may be viewed against the backdrop of a new generation of studies on women and their financial and time commitments to the household. defined as a particularly dense center in a network of

exchange relationships (Ciuyer 1980) and core activities (Netting, Wilk, and Arnould 1984). These studies (e.g., Bruce 1989; Dwyer and Bruce 1988; Folbre 1986a, 1986b; Hoodfar 1986, 1988, 1990; Loufti 1980; Wolf 1990) have questioned the joint utility model of the altruistic household as pursuing the interests of the collectivity (Becker 1976, 198 1 ) and the extent to which co-residence translates into shared production, reproduction, and consumption responsibilities. Attention has been focused on intrahousehold competition over resources and power relations by gender and generation, as translated into time and resource contributions and distribution patterns. Sensitive to changes in implicit rights and obligations as they pertain to resource flows, these studies have identified new consunlption patterns as factors affecting household relations. Questioned has been the optimistic view that capitalism will have a liberating effect on Third World women (Caldwell 198 1 ). The importance of this literature for international health is substantial. It calls attention to both the independence of and interdependence among household members; the cross-gender effects of changes in work and wages; the ways in which political economy and technology influence the distribution of resources and time within the household; and the reallocation of time as it affects the household production of health (Berman, Kendall, and Bhattacharyya 1988; Schumann 1991). Research issues that develop from this perspective include such topics as changes in women's work as it relates to male contributions to the household (in cash. kind, and time); female autonomy and decision making; and the overall effect changes in the mode of production have on nutrition, health care consumption, and patterns of morbidity and mortality. Few studies have examined the consequences of the trade-off that mothers make when they sell their labor time, thereby sacrificing parenting time. in order to secure needed resources. ' Questions emerge about the impact of alternative childcare (sibling care, grandmother care) on the household production of health. In order to address these questions, baseline data are required about the developmental niche (Super and Harkness 1986). Such data might include the jural status of children, psychological stimulation and observations of means of control, as well as nutrition, hygiene, and health care. Complementary data are needed on how mothers compensate for decreased parenting time in terms of substituting commodities for physical presence (e.g., treats, pocket money, over-the-counter medicines) and the impact of this behavior. New patterns of women's work also call for research on the ilnportance of the elderly as child care providers, their changing status within kinship-networks, and other communal arrangements. Coreil's article focuses on household time availability, health care seeking, and acceptance of health interventions ranging from oral rehydration therapy (ORT) to immunization. Time availability is assessed in terms of kinds of care and domains of care. She points out that the relative benefits and burdens of health and development programs have not been assessed in terms of the availability of labor and time demands in households having different structures and compositions. Echoing one of the important contributions of the "new household economics" (Becker 1976), Coreil emphasizes that the consumption of goods inclusive of health fixes like ORT involves two sets of costs: both direct costs and the indirect and opportunity costs entailed in acquiring, preparing, and consuming the product. To these costs she adds a third-social relational costs, inclusive of the

embarrassment some women experience when consulting health care providers who chastise them in public. The potential of overburdening mothers with more work in the name of primary health care is raised. Suggested are health care programs which are adapted to the time demands and schedules of busy mothers. In terms of health care seeking, Coreil points out that increased availability of adult care providers facilitates health care seeking outside the home while noting that the availability of the mother is most crucial in seeking health care for infants. Significantly, she points out that maternal availability is not just a question of time but of a mother's own health status. Nichter and Cartwright also point to the health status of adults and its effects on the household production of health. In this case, the highlighted cause of i l l health is tobacco use. Mortality and chronic disease are discussed in relation to their impact on the household unit, not just on the afflicted. The degree to which they affect the household will depend on prior household composition and patterns of gender contribution. Female-headed households will suffer far less from the death or disability of a male than households where women are dependent on male contributions for survival. Even in female-headed households, however, caring for an afflicted male may constitute a significant drain on household resources. Juxtaposed in their essay is the relative success of child survival programs and the growing health problems affecting adults who have the added responsibility of caring for the young as well as the old. In reference to the new generation of household studies noted above, cigarette consumption is also important to consider in relation to changing patterns of household contribution. As noted by Bruce (1989) and Hoodfar (1988), consumption of items like cigarettes is becoming as important to the social role of males as work. Male contributions to households are based not only on percentages of income earned or responsibility for the purchase of particular goods and services, but also on the amount of cash remaining after established personal habits have been met. Conflicts within households have been reported worldwide that have to do with shifting patterns of personal consumption and feelings of entitlement to resources. Entailed are conflicts of values related to coexisting ideologies of individual and corporate self, fostered by capitalist and precapitalist modes of production. In their discussion of the tobacco industry, Nichter and Cartwright invite anthropologists to become more actively involved in the study of defective modernization (Simonelli 1987) as a process influencing health transition. They attempt to go beyond a world systems approach to the study of the tobacco industry. Nichter and Cartwright suggest that anthropologists need to study the mode of consumption in addition to the mode of production. They should examine the logic of stimulation which guides consumers to project their desires onto produced goods through propagated meanings fostered by the rhetoric of advertisements (Baudrillard 1988: 13). The study of defective modernization, as the introduction of smoking implies, needs to go beyond the study of tobacco and liquor consumption to other features of the modern world that prove defective, such as medications which promise commodified health in the context of a deteriorating environment and unhealthy working conditions (Nichter 1989a). Kendall et al. draw attention to the rapidly changing urban environment and a new set of health problenls which defy traditional approaches. Little medical

anthropological research has been carried out in urban areas, although researchers predict that half the world's population will live in urban areas by the turn of the century. Through their discussion of "community" recognition of dengue, a vector-borne urban disease, the researchers introduce several issues germane to anthropology in international health. Stacy Pigg (1990) has recently called into question representations of the community as prornoting developrnent ideology and framing local identity. While her work is primarily focused on irnages of the typical generic village, Kendall et al. turn their attention to the urban context and ask how community or neighborhoods are defined for development purposes. Just as the household has had to be disaggregated, so too urban communities may best be defined in relation to activity sets. With respect to health, this means that communities are constituted by common motivations to solve health ~ r o b l e m s In urban contexts it is difficult to mobilize action sets around health problems like dengue because of competing priorities among health concerns, as well as competition between health priorities, on the one hand, and investment in life styles, forms of architecture. and use of social space, on the other. In order for dengue to be controlled, a high level of community participation is required. How this is to be accomplished requires anthropological research centered not only on the disease but on changing social relations in the context of modernity. Although discussions of modernity have focused on psychological characteristics, the most interesting issues are related to institutional features (Giddens 1990). The modern city projects across space and time, ordering the activities of an enormous population. The paradox of these vast cities is that they inadequately penetrate the lives and living conditions of many of their inhabitants, while at the same time they disassemble rnany local institutions such as the family, household, and comrnunity. Planners can rely neither on the formal institutions of the city or the state nor on traditional cultural responses, associations, or sodalities to solve problems. This is particularly true when health problems are insidious and practically invisible. The epidemic of dengue hemorrhagic fever in Venezuela, which is mentioned by enda all and his colleagues, was not due to an accident but to the invisible circulation of several serotypes of dengue virus transmitted by the mosquito. The health "problem" is the maintenance of transmission pathways, such as disease transmitting mosquitoes, or poor hygiene, although it is only noticed when an explosive epidemic occurs. Case studies such as dengue call into question characterizations of health transition that emphasize education as a primary factor affecting health. In addition to increased knowledge and the autonomy associated with it, there is a complex of social factors involved in enhancing health at the household as well as "community" level. The conceDt of the health transition (Caldwell and Santow 1989: Caldwell et al. 1990) hints at the complex economic and social structural interactions that created the conditions for improving health, but the practical applications of this concept have focused on individual agency, as opposed to structure. Contemporary, post-transition health problems will not be solved by either simple technologies or preoccupation with agency. Instead, they will require an exploration of econon~ic,and syn~bolic-and understanding of gender, structures-social, class, household, ethnic, and conlmunity dynamics, and will require interventions

explicitly multisectoral. The bridge between applied approaches and critical and distanced ones will be constructed out of necessity. From research driven by international health programs, we must move to research responsive to processes of change in the postmodern world. 'Few studies exist on women's labor force participation and the impact of reduced parenting time on the household production of health. Studies from Malaysia (DeVanzo and Lee 1983) and the Philippines (Popkin 1980: Popkin and Solon 1976) have reported decreased nutritional well-being among the poor.

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References Cited The Anthropology of Infectious Disease Marcia C. Inhorn; Peter J. Brown Annual Review of Anthropology, Vol. 19. (1990), pp. 89-117. Stable URL: http://links.jstor.org/sici?sici=0084-6570%281990%292%3A19%3C89%3ATAOID%3E2.0.CO%3B2-F