University of Amsterdam
Faculty of Social and Behavioral Sciences
Tudor Georgescu
Student no.: 0367265
Student e-mail:
Do Medical and Cultural-Economic Factors Explain the Health Status of the Infants of the World?
Second Semester, 2006-2007
Individual Bachelor Research
Coordinator: Professor Herman van de Werfhorst
1.Introduction
2.Theories and Hypotheses
2.1.Medical Factors
2.2.Education
2.3.Economy
2.4.Set of Hypotheses
2.5.First Model
2.6.Second Model
2.7.Studying Different Sets Separately
3.Data Description
4.Operationalization
4.1.Preliminaries
4.2.Building a Medical Index based upon HDR 2006 Data
4.2.1.Operationalization for First Model
4.2.2.Operationalization for Second model
4.3.High Human Development
4.3.1.Operationalization for Model 1.H
4.3.2.Operationalization for Model 2.H
4.4.Medium Human Development
4.4.1.Operationalization for Model 1.M
4.4.2.Operationalization for Model 2.M
4.5.Low Human Development
4.5.1.Operationalization for Model 1.L
4.5.2.Operationalization for Model 2.L
5.Results
5.1.General
5.2.High Human Development
5.3.Medium Human Development
5.4.Low Human Development
6.Conclusions and Policy Recommendations
7.Bibliography
1.Introduction
In this paper I try to assess some of the causes of infant mortality, by considering which factors (medical and non-medical) contribute to this problem. The question is: do medical and cultural-economic factors explain the health status of the infants of the world? If yes, how do they explain it?
Seeing infant mortality as an important indicator of the effectiveness of medical care, I analyze its correlation with economic, cultural and medical factors, as reported by the Human Development Report 2006.
This is a quite relevant problem, for we may consider that death of one’s infant is a very serious event in a parent’s life, and high levels of infant mortality are likely to produce feelings of profound dissatisfaction, even rebellion, in a given population. Such feelings would burst out in revolts, and these, in their turn they would loop back, aggravating the problem being considered. But this is the subject of another paper (Georgescu, 2006).
I have to make it clear that I do not simply research the medical causes of infant deaths, as in terms of infections, illnesses and injuries, but I research the economic, cultural, social and institutional factors, including variables referring to the medical system.
A physician is in the first instance concerned with the medical causes of a given decease. A sociologist is concerned with the correlations between medical, nonmedical factors and the infant mortality. The physician is in the first instance concerned with the purely medical side of mortality, as infection prevention, therapy, hygiene, input of vitamins and nutrients and so on. A sociologist is concerned with the social, cultural, economic and even medical factors which produce infant mortality as a social phenomenon. The existence of such publications as Social Science and Medicine proves that both professions share a concern for the medical implications of the social factors.
2.Theories and Hypotheses
2.1.Medical Factors
Wikipedia (2007: ‘Infant mortality’) considers that the most relevant factors which produce infant mortality are: congenital malformation, infection and SIDS (Sudden infant death syndrome, aka cot death or crib death). The same source also shows some sources of bias in accurately reporting infant mortality, but for the sake of this research such bias will be bracketed, and we decide to trust the figures which make sense for World Health Organization and for the UN Development Programme.
Human Development Report 2006 focuses on water. I quote: “The absence of clean water and adequate sanitation is amajor cause of poverty and malnutrition: …Diseases and productivity losses linked to water andsanitation in developing countries amount to 2% of GDP,rising to 5% in Sub-Saharan Africa—more than theregion gets in aid. … Dirty water and poor sanitation account for the vast majorityof the 1.8 million child deaths each year from diarrhoea—almost 5,000 every day—making it the second largestcause of child mortality.Access to clean water and sanitation can reduce the risk ofa child dying by as much as 50%.” (Watkins c.s., 2006:22-23).Sanitation is relevant, since having improper sanitation contributes to spreading diseases (Ibidem:45).
The purpose of health expenditure of a country is to attempt to render its population safe from diseases, and attempt to ensure a reasonable level of health for everyone there (cf. Georgescu, 2006:13).This indicator is half-way between a purely medical factor and a socioeconomic factor.
The size of the medical system of a country could be estimated, in a certain respect, by the number of physicians per hundred thousand inhabitants (cf. loc. cit.).We would thus expect that countries which have more physicians per hundred thousand inhabitants, they have a lower infant mortality, since the size of the medical system is larger.
Having a birth assisted by a skilled medical professional, it is more likely to produce a sane and viable offspring, since there is prompt and professional intervention in case of medical problems arising at birth (cf. Ronsmans et al., 2002).
2.2.Education
A great deal of education of the parents aims at educating them in the spirit of taking care of their own hygiene (cf. Haggerty et al., 1994); therefore they develop good habits for raising their infants, too, if they are properly educated. There are countries where schooling is a privilege, not a right, and this could be relevant to this problem. And, as shown by Muller (2002), education is a good predictor of mortality.
And, in this respect, educational participation is relevant, since education aims (among other purposes) at educating men and women for taking proper care of their own hygiene and taking care of the hygiene of their infants. Education imparts essential information about hygiene and gives people basic information about the medically adequate ways to handle and treat diseases. In this respect, it is about the process of enlightenment, as propagated by Hobbes(cf. Strauss and Cropsey, 1987:917), meaning that people are enlightened through participating in the scientific insights imparted through education.
Education also imparts some basic medical information about the causes and the remedies for specific illnesses, e.g. a parent should know that an infant can be saved from diarrhea by oral rehydration solutions (Watkins c.s., 2006:43), and not through incantations for the spirits done by the medicine man. This insight can be taken for granted in Western countries, wherein education is compulsory up to a given age, but it is not self-understood for a population lacking literacy and access to education.
There is an ecological fallacy if we would prove some statistically significant group characteristic and we would pretend that it applies to individuals inside that group. But, the reverse way is true in this situation: we assume that education changes individual behavior and we seek to verify or falsify this insight according to the following scheme:
(i)Education changes the behavior of individuals.
Therefore, we would expect that:
(ii)Mass education changes the behavior of large groups of people; the more educational participation/alphabetization, the larger the behavior change is.
So, we assume (i), and verify that it has the real effect according to (ii). The implication is from (i) to (ii), not from (ii) to (i). Drawing the implication from (ii) to (i) would be an ecological fallacy, but there is no ecological fallacy in (i) implies (ii). (i) is assumed and we check if (ii) holds, which could (eventually) falsify (i) in a modus tollens.
2.3.Economy
And of course, the richer the country, the more readily available is good quality food (vitamin-rich food and food safe from infection and degradation), and itslevel of wealth influences the factors named above. According to C.W.S. Monden (2005), lack of material resources is a very relevant cause of overall mortality, i.e. the rich are in a position to live longer and healthier than the poor.The same remark about ecological fallacy applies here, too.
We may make the observation that highly developed countries are rich and therefore can afford paying for compulsory mass education[i] (up to a certain age, function of country). But, this should be obvious. It confirms our intuitions through and through, for who wouldn’t expect that rich/more developed countries have a lower infant mortality than other countries, which are not so rich and developed? This is common sense.
So, a certain amount (no 100%!) of economic determinism cannot be avoided in these matters. Proper mass education and big health expenditures require that such country has the necessary monetary resources to pay for them. But, among countries of similar richness, there could be differences in grating funds for education and health systems, instead of, let’s say, military industry.
2.4.Set of Hypotheses
Considering these factors, we met in scientific literature the following hypotheses: infant mortality is lower when:
-the percentage of population having access to improved water is higher;
-there is more access to proper sanitation;
-the medical expenditure per capita is larger;
-there are more physicians per hundred thousand people;
-the percentage of births assisted by medical professionals is higher;
-the education index is higher;
-the GDP index is higher.
The hypotheses about various medical factors shall be analyzed in a complex indicator based on the five medical factors named above.Having these hypotheses in mind, we will look at each of the high, medium and low developed countries, and test these hypotheses for a given set of countries only.
The logical scheme of the analysis is (following the example of Baer and Graves, 2002):
2.5.First Model
2.6.Second Model
In the first instance we will compute the influence of the medical factors upon infant mortality and then input economic and cultural factors, in order to show that they reduce the statistical effects of the medical factors. For, from the theories mentioned before, we inferred that medical factors are not the only thing that counts, in respect to this problem.
Since the economic determinism is no 100%, we assume that the variables above are quasiautonomous, that theyare influenced by GDP, without speaking of full determinism[ii].The economic determinism is not purely causal. The analysis is rather culturalistic than structuralistic; economic development is not the only factor that matters. The variable “Behavior” is only there for the sake of clarity, and it is not operationalized.
2.7.Studying Different Sets Separately
We noticed that Navarro c.s. (2006) studied only OECD countries. Thus, keeping the world index[iii] constant, we may do a comparison between countries of a similar development level. We reduce thus the variance due to differences of HDI Index (which is determinant for the world index, since world index classification is directly based upon HDI Index) and which is a factor which is strongly correlated with infant mortality (it will be shown in “Operationalization/Preliminaries”). We make then a comparison between a set of countries which are more equal in respect to mortality, as I will show there by computing certain correlations. Iwill thus show that the world index is very relevant in respect to inequality of mortality and this factor is strongly correlated with infant mortality (cf. Smits and Monden, 2006 for the concept of inequality of mortality).
We will make comparisons inside rather egalitarian sets of countries, in order to make abstraction of the source of highest inequalities of infant mortality, namely the development level of a given country. Since this development level, expressed by the Human Development Index, decides whether a country has high, medium or low human development, it follows that in making such comparisons we seek to remove most of the variation due to differences due to world index, in order to understand which specific factors play a role inside each of the sets of countries, in respect to this problem.
We have thus a view on the analyzed issue which looks at the developments inside each set, taken apart from the other sets. So, from a policy making viewpoint, there will result methods for helping countries of medium human development reduce its infant mortality, different from the methods for helping countries of low human development about such an issue (cf. Ronsmans, 2007). This is because the causes of infant mortality could differ among such sets of countries, as there are many differences among these sets.
E.g., we could perhaps assume that in many countries of high human development basic education is compulsory, while in many countries of low human development, it remains a privilege. A higher educational participation would imply that parents are more aware about hygiene and health issues (see the discussion on ecological fallacy above), and about the optimal methods of raising their babies, given their circumstances. It follows that, given such assumed differences between medium and low human development, educational participation would have more influence upon the variation of infant mortality in the countries of low human development that in countries of high human development. We will see if this hypothesis can be verified or falsified. All previous hypotheses will be tested on these sets, too.
Making an analysis of three different sets of countries, all the difference due to GDP index and education index could eventually be attributed to the human development level. This would be fine for so long as we don’t notice that education index and
GDPindex are an integral part of calculating the HDI index (which statistically expresses human development level; formula for HDI index is reported under “Operationalization/Preliminaries”).
3.Data Description
I employ the data provided by Human Development Report 2006. The data is provided free of charge (yet copyrighted) by the Human Development Report team, and it can be downloaded freely from
I will quote from HDR 2006 (Watkins c.s., 2006:404-410):
“GDP index=One of the three indices on which the human development index is built. It is based on gross domestic product per capita (in purchasing power parity terms in US dollars; see PPP).”
“PPP (purchasing power parity)=A rate of exchange that accounts for price differences across countries, allowing international comparisons of real output and incomes. At the PPP US$ rate (as used in this Report), PPP US$1 has the same purchasing power in the domestic economy as $1 has in the United States.”
“Population, total=Refers to the de facto population, which includes all people actually present in a given area at a given time.”
“Literacy rate, adult=The percentage of people ages 15 and older who can, with understanding, both read and write a short, simple statement related to their everyday life.”
“Enrolment ratio, gross combined, for primary,secondary and tertiary schools=The number of studentsenrolled in primary, secondary and tertiary levelsof education, regardless of age, as a percentage of thepopulation of official school age for the three levels. Seeeducation levels and enrolment ratio, gross.”
“Education index=One of the three indices on whichthe human development index is built. It is based on theadult literacy rate and the combined gross enrolmentratio for primary, secondary and tertiary schools. Seeliteracy rate, adult, and enrolment ratio, gross combined,for primary, secondary and tertiary schools.”
“Water source, improved, population with sustainableaccess to=The share of the population with reasonableaccess to any of the following types of watersupply for drinking: household connections, publicstandpipes, boreholes, protected dug wells, protectedsprings and rainwater collection. Reasonable access isdefined as the availability of at least 20 litres a personper day from a source within 1 kilometre of the user’sdwelling.”
“Sanitation facilities, improved, population withsustainable access to=The percentage of the populationwith access to adequate excreta disposal facilities,such as a connection to a sewer or septic tank system,a pour-flush latrine, a simple pit latrine or a ventilatedimproved pit latrine. An excreta disposal system isconsidered adequate if it is private or shared (but notpublic) and if it can effectively prevent human, animaland insect contact with excreta.”
“Physicians=Includes graduates of a faculty or school ofmedicine who are working in any medical field (includingteaching, research and practice).” Note: the corresponding statistical indicator inside HDR2006data expresses the number of physicians per hundred thousand inhabitants.
“Births attended by skilled health personnel=The percentageof deliveries attended by personnel (includingdoctors, nurses and midwives) trained to give the necessarycare, supervision and advice to women during pregnancy,labour and the postpartum period; to conductdeliveries on their own; and to care for newborns.”
“Health expenditure per capita (PPP US$)=The sumof public and private expenditure (in purchasing powerparity terms in US dollars), divided by the population.Health expenditure includes the provision of health services(preventive and curative), family planning activities,nutrition activities and emergency aid designatedfor health, but excludes the provision of water and sanitation.See health expenditure, private; health expenditure,public; and PPP (purchasing power parity).”
“Health expenditure, private=Direct household (out ofpocket) spending, private insurance, spending by nonprofitinstitutions serving households and direct servicepayments by private corporations. Together with publichealth expenditure, it makes up total health expenditure.See health expenditure per capita (PPP US$) andhealth expenditure, public.”
“Health expenditure, public=Current and capital spendingfrom government (central and local) budgets, externalborrowings and grants (including donations frominternational agencies and nongovernmental organizations)and social (or compulsory) health insurance funds.Together with private health expenditure, it makes uptotal health expenditure. See health expenditure per capita(PPP US$) and health expenditure, private.”
“Life expectancy at birth The number of years a newborn infant would live if prevailing patterns of age-specific mortality rates at the time of birth were to stay the same throughout the child’s life.”