A few thoughts on Public Health

Health Stations at Fila Grande, Matagalpa

For its 2000-01 World Development Report, the World Bank interviewed 60,000 people in 47 countries about what relief of poverty meant to them. They could say anything. What do YOU think the most frequently mentioned answers were? I immediately thought not being poor meant having a house, running water, a reliable source of income, access to health care, food always on the table. But those weren’t the answers. Rather, people who don’t have anything wanted “opportunity,” “empowerment,” and “security” over everything else. They just want to feel like people.

Amartya Sen defined development as “the freedom to lead the life people have reason to value.” In both rich and poor countries, the poor define poverty as “not being able to participate fully in society” and having limits on leading life the way one imagined. So when talking about improving the health of the poor, we talk about decreasing their poverty. But decreasing poverty isn’t just resolved by giving a person a house and clean water, it means fundamentally changing the way they view themselves in society. 

There is a famous public health study, called the Whitehall study, that looked at the 25-year mortality follow-up of British civil servant men, originally aged 40-69, by age of death. The study looked at the link between relative rates of death and position in occupational hierarchy. As you can see, those in administration die at a lower rate than those in the professional/executive rank. And those in the professional/executive rank live at a lower rate than those in the clerical rank.



















You might venture to explain the poor health of the lower ranking individuals as a result of dirty water, inadequate nutrition, or lack of shelter… but Whitehall, England is not a village or a slum. The residents of Whitehall have clean water, bathrooms, an excess of calories to eat, and shelter.

So the question is: Why do the civil servants, none of whom are destitute, that rank second from the top of the occupational hierarchy have a higher rate of death than men at the top? The answer is MIND. BOGGLING. And opened a whole new facet to health that I hadn’t thought about before= Self-perceived health and empowerment.

Essentially, the Whitehall study showed that absolute income as a determinant of health is less important than how much one has relative to others. Relative income as Sen notes, translates into capabilities. What you have isn’t as important as what you can do with what you have. Hence, one explanation for why the civil servants at the bottom of the hierarchy have poorer health than those at the top, in spite of having all resources necessary to maintain good health, is that these civil servants feel and think that they do not have control of the way they lead their lives. They do not have the freedom to lead a life they would value, because their capability to do so is determined by their social conditions.

So my question becomes, as a pre-med student wants to improve the health of the poor, how in the world could I possibly change someone’s self-perceived empowerment? How do you make someone feel as though they have control over their lives?

There was another study (last one, I promise) of 11-12 year old children in India where high caste and low-caste children were given mazes to solve. Despite the high-caste children having higher levels of parental education, the two groups of children did identically on the tests. The tests were then repeated but this time attention was drawn publically to the caste of the children. Under these circumstances, under this additional pressure, the lower-caste children did substantially worse. Researchers think this is decrement in performance of the lower-caste children is a result of the lower-caste children expecting to be treated less fairly. It was the low-caste children remembering their “powerlessness.” Power, then, is key. Both actual power AND self-perceived power. Control, autonomy, and freedoms might sound like psychological properties only affected by the perception of the individual himself, BUT power relations in society, as they operate though societal social structures and the associated opportunities for each rank in the structure, have a HUGE IMPACT on degrees of empowerment.

So after all these British civil servants and Indian children, I’ve learned that improvement in health of disadvantaged people is built on two intertwining pillars: 1.Material conditions for good health: food, water, sanitation, accessibility of medical services AND 2. Control of life circumstances.

I’ve learned that people’s opportunities to control their lives, to be empowered, and to participate fully in society are heavily determined by the way we organize our affairs in society. And after seeing the structure of AMOS’s community-based participatory health program, I’m convinced that the model works towards empowerment and has potential to make great change. AMOS’s model focuses on empowerment of disadvantaged people, by training a rural health promoter, focusing on community education, and introducing micro-finance businesses, and in this way, AMOS is able to change perceived control and opportunities. I’m not saying AMOS’s model is perfect, because horizontal, comprehensive approaches tend to be less cost effective, and they take longer to see change. And I’m not really even sure there is a way to fully address the way someone views his or her own freedom. I’m just saying that, keeping in mind this importance of empowerment in improving health, I think AMOS’s model is pretty darn effective.

Stats, studies, and graphs primarily drawn from: “Health In an Unequal World” by Michael Marmot. Marmot is the director of the International Institute for Society and Health, and a professor of Epidemiology and Public Health at University College London. Best of all, he received a knighthood for his work in public health from the Queen. Take a seat at the round table Elton John, Marmot is now the coolest knight I know of.