Health Transition: The Cultural, Social and Behavioral Determinants of Health in the Third World

Citation: Caldwell, John C. (1993) Health Transition: The Cultural, Social and Behavioral Determinants of Health in the Third World.
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Tagged: uw-madison (RSS), wisconsin (RSS), sociology (RSS), demography (RSS), prelim (RSS), qual (RSS), WisconsinDemographyPrelimAugust2009 (RSS)

Summary

Explanations for the health transition (i.e., epidemiological transition) have been forwarded by McKeown, who argues for the importance of improved nutrition, and Szreter, who argues that public health initiatives are the key factor. However, contemporary studies of the third world indicate that factors outside of lifestyle improvements and public health/medical interventions are also quite important in understanding the health transition. A study by the Rockefeller Foundation juxtaposed countries with good health but very low income ((e.g., Kerala (a state in India), Cuba, China)) to countries with poor health but relatively high income (e.g., Saudi Arabia, Iran, Algeria). It found that social and cultural variables are responsible for the difference-the most important of which is the "educational levels of women of maternal age, followed closely by the practice of family planning and the education of men, and more distantly by the density of doctors and nutritional levels, while there was weak correlation with per capita income" (p. 126). Also, a U.N. study of 15 developing nations showed that an added year of mother's schooling reduced child mortality by nearly 6.8%. (Note that while the introduction of control variables halved this association, there are reasons to suspect that it is biased downward and, in any case, is still a very important effect). Because of the importance of education on child survival, Caldwell focuses much of the remainder of the article on the questions of how and why education achieves this result. "A study in rural south India showed that young mothers who had been to school were more likely to demand . . .that a sick child be treated, and more likely to use modern medical facilities in the form of the health center; spend a longer time with the doctor explaining the problem and listening to his instructions, were more likely subsequently to follow those instructions, and were much more likely to report back to the center if the patient was not recovering." (p. 128). Several points can be derived from this case: (1) Educated women feel welcome in the "non-traditional" world of modern medicine and are hence more likely than the uneducated to make use of its services. (2) Educated women are less intimidated by physicians and more likely to interact vigorously with them. (3) Educated women are more likely to report failed treatments to doctors, whereas the uneducated are more likely to fear negative responses from physicians. Caldwell argues that the effectiveness of health care is not dependent on the sophistication of medical knowledge, but rather on "the belief of the populace that this is the correct knowledge and that they can or should collaborate with it to reduce mortality" (p. 130). Therefore, Caldwell asserts, "The impact of modern medicine in Third World societies can be very modest. It can, however, be spectacular if it is accompanied by modern education. The reason is that modern education around the world is essentially Western education, and it carries a powerful Western pro-science message" (p. 131, emphasis mine). In other words, education provides the basis for mass cooperation with medical interventions. When entire societies or ethnic groups within countries exhibit counter-Western cultures (e.g., Middle Eastern societies), then they may not fully utilize the capabilities of modern medicine. Factors other than education, culture and ethnicity that influence the health transition are radicalism, egalitarianism, individualism and democratization. Not surprisingly, these factors endow societies with qualities similar to modern education (e.g., individual responsibility, the undermining of traditional beliefs and social roles, etc).