Global Perspective on SDoH

Question 1

Global Comparisons

Answer 1

• Population level on health indicators helps us see how global health inequalities persist
• These inequalities are associated with a country’s economic status (income, wealth); distribution (inequality); social development; and political context
• Provides us with a ‘big picture’ – inequalities exist within countries
• Allows for comparison, correlation and further analysis

Question 2

Global Contexts

Answer 2

• Taking a global perspective also means examining how social determinants are shaped by economic, social and political factors on a global scale
• What factors produce differences in countries’ economic status; inequality levels; social development; political context?
• How do international relations, policies, and norms (historical and contemporary) shape contemporary national contexts?

Question 3

Paul Farmer’s Work in Haiti

Answer 3

• physician and anthropologist
• Has worked in numerous countries and communities including Haiti and Rwanda
• Has worked to establish community health models to treat disease
• Addresses the role of poverty and inequality in producing health inequalities and ‘extreme suffering’
• Uses the stories of Acéphie and Chouchou as exemplary – demonstrate the ‘pathways’ by which social determinants affect health in Haiti

Question 4

Context in Haiti

Answer 4

•Poorest country in the Americas, with worst health indicators (highest infant mortality and maternal mortality rates; highest malnutrition rates; and highest number of persons living with HIV/AIDS)
•Over 6 million people (59% of the population) live below the poverty line of US $2.41 a day
•Over 2.5 million (24%) fall below the national extreme poverty line (US $1.23 per day)
•One of the most unequal countries in the world
•Life expectancy at birth (m/f) is 61/66 years
•Infant mortality rates of 80.3 per 1000 live birth in 2000
-Attributed to increased poverty, impact of AIDs, and poor health systems

Question 5

Acephie-> Family Poverty

Answer 5

• Lost land, property and income generating activities due to flooding of the valley where they lived
• Sexual relationship as a survival strategy

Question 6

Acephie-> Working Conditions

Answer 6

• Rural isolation and limited opportunities

* Walk by soldiers – in a position of power – sexual harassment

Question 7

Acephie-> Gender Expectations

Answer 7

• Limited ability to say ‘no’ due to power differential
• Poverty and limited opportunities make sexual relationships a survival strategy
• Multiple sexual partners means higher risk of spreading infection
• Lack of accountability from new partner once ill
• What supports did Acéphie have once her child was born?

Question 8

Acephie-> Political Context

Answer 8

•Political violence kept clinic from being open; limited access to healthcare during pregnancy

Question 9

Chouchou-> Political Disenfranchisement

Answer 9

• Lack of political power of those in rural areas
• Violent regime → even veiled criticism punished by violence
• Lack of political accountability, including through media

Question 10

Chouchou-> Gender Relations

Answer 10

•Men more commonly targeted for political violence and torture

Question 11

Chouchou-> Poverty & Economic Opportunity

Answer 11

• After initial arrest, blacklisted

* Property seized

Question 12

Global Suffering Stats

Answer 12

• AIDS and political violence are two of the leading causes of death among young adults in Haiti
• They are the consequences, directly or indirectly, of human agency
• Suffering is ‘structured’ by historical and economic processes that constrain agency

Question 13

WHY IS GLOBAL SUFFERING DIFFICULT TO ADDRESS?

Answer 13

• We are often less empathetic to suffering of those we see as ‘other’ or ‘different’
• The sheer weight of suffering makes it difficult to represent and to understand
• Dynamics and distribution are still poorly understood

Question 14

Geographically Broad

Answer 14

• The world is increasingly interconnected; countries do not exist in a vacuum
• Countries that are dependent on international aid can be influenced by the interests of the more powerful (e.g. Washington’s support for the Péligre dam; for military rule)

Question 15

Historically Deep

Answer 15

• History of the Péligre dam and displacement

- Go further…history of colonialism and slave trade that led to economic vulnerability and lack of international power

Question 16

Simultaneous/Intersectional

Answer 16

• No one factor can fully explain health outcomes

- Must look at various axes simultaneously

Question 17

Intersectionality

Answer 17

• Theory developed by Kimberlé Crenshaw in relation to Black women’s experiences of violence
• The way in which our identities/social positionings intersect to create unique experiences of both privilege and oppression
• Intersectionality is not additive!

Question 18

Examples of Intersectionality for Acephie

Answer 18

• gender norms made sexual relationship a socially acceptable survival strategy; this strategy was made necessary by poverty
• a truly intersectional approach does not attempt to hierarchize, but to analyze each aspect in relation to each other
• While we may attempt to ‘triage’ social determinants, it is important not to use hierarchy to dismiss forms of oppression

Question 19

The effect of SDoH on Gay Men

Answer 19

rich gay men were also negatively affected by the lack of research and health services provided during the early years of the AIDS crisis in the United States

Question 20

Axes of Gender

Answer 20

• Helps explain why Acephie died of AIDS and Chouchou died from torture
• Gender systems in which women have less power →increased vulnerability to domestic and sexual violence,
  e. g. Poor women, women of colour most vulnerable

Question 21

Axes of “Race” or “Ethnicity”

Answer 21

• Racism used to deprive groups of rights and justify inequality and suffering
• Often used by colonial powers to divide and conquer e.g. Rwanda
• Although linked to resources, also related to social disenfranchisement and chronic stress

Question 22

Other Axes

Answer 22

Homophobia and sexuality

-Geographic location

Question 23

History of the Péligre Dam

Answer 23

• Displacement of landowners
• Negative overall effect on agricultural production
• Produces rural poverty and makes vulnerable those who had previously been able to sustain themselves
• Supported by Washington: alignment with dominant ideologies of ‘development’

Question 24

Political Dictatorships

Answer 24

•François “Papa Doc” Duvalier from 1957-1971
•Jean-Claude “Baby Doc” Duvalier from 1971- 1986
-Agreement with Reagan administration not to accept refugees from Haiti
-Corruption, stole money, extreme violence
•Coup d’etat ends first democratically elected
government and brings military rule 1991
-Supported by foreign aid from the US
-Continued regime of violence

Question 25

THE PÉLIGRE DAM

Answer 25

built in the context of support for large-scale, infrastructure projects funded by the state and by international aid/loans

Question 26

Modernization...

Answer 26

theory posited that economic development could only be achieved by modernizing economies→replace agriculture with industry -Modernization theory itself based on the belief that ‘underdeveloped’ countries are ‘backwards’ and need to be modernized; little acknowledgement of how economies, political systems and natural resources were decimated during colonial era •Led to accumulation of debt for infrastructure projects that could not be maintained and/or did not benefit the most marginalized •At times served the interests of the most powerful (national and global)

Question 27

Neoliberalism

Answer 27

oPosits that the market is the best means of distributing resources → privatization of government services, including healthcare oMinimize the role of the state → dismantling of welfare systems, social services and regulations oFree trade → low income countries unable to use tariffs or subsidies to protect and grow national economy

Question 28

Structural Adjustment Programs

Answer 28

controversial conditions attached to IMF and World Bank loans in 1980s and 1990s (including to Haiti) - Required cuts to state spending, opening of borders and privatization - Largely regarded as a failure – did not produce economic development and led to huge increases in both inequality and poverty - Reduced state spending on healthcare associated with poorer health outcomes; other social determinants also affected (education; food security) - Women particularly affected; greater economic vulnerability; increased risk of domestic violence; increased burden of care; maternal health and mortality

Question 29

Universal Healthcare Access

Answer 29

attitudes towards structural adjustments have changed (for some more than others) -More acknowledgement of the importance of state provided services such as health and education -World Bank now supports universal healthcare as part of social development •Not a move away from neoliberalism – but a softening of its effects •World Health Organization now identifies poverty as the world’s leading killer •policy continues to focus on increasing access to healthcare rather than on social determinants -(e.g. Canadian maternal health policy – no analysis of gender and/or poverty)