International Journal of Social Determinants of Health and Health Services

Millions of people in the less developed world are currently living in an economic depression. In this article the author outlines the relationships between debt, depression, and public health in less developed countries, with a special emphasis on who is incurring the debt and who is paying for it and why. The article concludes with a case study that illustrates an alternative to underdevelopment and presents some generic policy options.

Decentralized forms of government are becoming more common in Western European countries. The effects of decentralization of public health services are explored in this article. In 1984 the Norwegian Municipal Health Act allocated the responsibility for primary health care to the municipalities. Based on data from a sample of 70 municipalities, the author shows that the number of primary health service personnel has expanded considerably during 1984–88, but the distribution of services has not become more equitable. Though the formal role of local politicians in the decision-making process has increased, the health sector officers and the Municipal Executives have in practice controlled the evolution of the municipal health services. The author concludes that decentralization does not necessarily lead to more democracy, and that an equitable distribution of public health services becomes more difficult to attain.

In a number of important developing nations—among them Indonesia, India, and Brazil—clinical pharmacologists and other drug experts are revealing mounting concern over the marketing of fraudulent drug products. These are shaped, colored, flavored, marked, and packaged to mimic the real product They may contain the actual antibiotic or other drug indicated on the label, but so “cut” that the product provides only a small fraction of the labeled amount, or they may contain only useless flour or starch. At best, they are worthless. At the worst, they can kill. In most instances, it is believed that these “drugs” are produced and marketed by local or domestic fly-by-night groups and not by multinational pharmaceutical firms. Blame for these practices is placed on inadequate or unenforced laws, only trivial punishments, bribery and corruption, and the fact that generally “nobody inspects the inspectors.”

Questions are posed and answered on synthetic bovine growth (milk) hormones (s-BGH), covering a wide range of areas of critical international concern. These areas include: the data base on s-BGH; efficacy and benefits to the dairy industry; veterinary effects; public health effects; Food and Drug Administration approval; and the FDA review process.

In one short decade, the politics of AIDS has become the politics of survival. In a world whose social order is changing before our eyes, AIDS insistently brings new meaning to the age-old question of what it is we must do to survive—as individuals, as families, as communities, as nations, as members of an interdependent world. The goal of this Special Section is to promote frank discussion, from an explicitly progressive perspective, of what it will take to stop the AIDS epidemic and deal with the devastation it has already wrought. Articles by AIDS researchers, service providers, and activists from around the world will address the numerous social, political, economic, and cultural factors that affect both the spread of AIDS and the social response to the epidemic. Topics to be considered in this and future issues of the Journal include: AIDS and community survival in the United States; women and AIDS, particularly in economically underdeveloped countries; the politics and economics of AIDS interventions in Latin America and the Caribbean; and the growing international AIDS industry.

AIDS prevention programs in the United States have been relatively successful in providing accurate information on AIDS to a wide cross-section of the population, but less successful in helping people to change their risk behavior. The most significant changes have been reported in urban gay men, with lower levels of change in drug users, and the least change in young adult heterosexuals. Various obstacles to effective AIDS prevention interventions have been identified, including too great an emphasis on information; a reliance on one-way rather than interactive communication; a narrow categorical approach to AIDS; a failure to integrate prevention and treatment services; an unwillingness to acknowledge widespread distrust of government, scientists, and health officials; and a focus on individual behavior rather than the social and political factors that shape behavior. To address these obstacles, AIDS educators should identify and strengthen those cultural forces that support prevention while also challenging those that block it. AIDS prevention programs need to be integrated into other programs serving community needs, especially into those grassroots organizations that can raise questions of gender behavior and drug use. While AIDS organizations should help meet the service needs of people with AIDS, they must also play a role in mobilizing communities to demand the resources they need to contain the further spread of the epidemic. Finally, AIDS prevention programs need to be linked to a vision of a better world in which the conditions that have contributed to the rapid spread of HIV infection are addressed and improved.

The characteristics and consequences of the AIDS/HIV epidemic in New York City are examined, with special attention to its impact on inner-city communities. The high numbers of AIDS cases are the source of increasing stress on public and community treatment and family and neighborhood networks of support. As the epidemic deepens (8 to 10 thousand new cases per year are expected by 1992) these resources, already weakened by years of underfunding, are becoming overwhelmed and are in danger of collapse. The high rates of HIV infection in these communities (5 to 20 percent of adults aged 25 to 45) and their linkage to widespread drug use prefigure the development of endemic levels in several population subgroups, with substantial risk of heterosexual spread. Simultaneously, there is a steady diffusion of infection to adjacent urban areas and, via migration patterns, to localities quite distant from New York City (e.g., Puerto Rico). Some hope can be found in the advent of more effective methods of early intervention for presymptomatic HIV infection. These offer an opportunity for combining clinical care with public health strategies that may restrict the spread of HIV while providing humane care for large numbers of people with AIDS and support for their families.

Pediatric AIDS cases constitute approximately 2 percent of total AIDS cases in the United States, but HIV infection and AIDS among children pose a growing concern. Government policies have failed to match the epidemiological reality of the disease. The powerful shapers of public opinion have dedicated their energies to a handful of cases, involving the school attendance of primarily middle-class children. Unfortunately, coverage of school placement issues has overshadowed both the demographically more serious issue of perinatally transmitted AIDS cases and the growing concern over adolescent AIDS. Seventy-five percent of perinatal AIDS sufferers are poor, urban minorities: the disease is clearly related to other indicators of poor child health—urban poverty and oppressive social conditions. School-based prevention efforts for adolescents have been rendered impotent because of moralistic obstacles to explicit education. Prevention of perinatal and adolescent HTV transmission must be both sensitive and relevant to communities in which the greatest threat to survival is poverty, not AIDS. Ultimately, issues surrounding pediatric AIDS only reinforce the long-term position of child health advocates: the best investment a society can make is a sincere commitment of resources to improve the health, education, and welfare of its children.

The concept of generational equity—that the nation is squandering its wealth on entitlements to the elderly while children remain impoverished—has received considerable media attention. The author traces the source of that message to an organization, Americans for Generational Equity, which is dedicated to restructuring the Social Security system along the lines of a social assistance program: reduced benefits available at later ages only to those who qualify through means tests. The impact of this agenda would be to increase the labor force participation of older people, particularly women and minorities, those presently without private pension coverage and already heavily represented in that sector of the economy where labor shortage is developing. Defining national spending priorities in terms of intergenerational conflict obscures the fact that Social Security is the only U.S. welfare program that has been successful in reducing poverty levels.

This article uses the social constructionist approach to social problems as claims-making activities and Blumer's theory of the developmental stages of social problems to analyze how elder abuse has been constructed as a social problem in Canada and how interest groups have been mobilized to deal with the alleged problem. Clearly, elder abuse has emerged as a social problem (often under the family violence rubric) and has received some legitimation from professional groups and representatives of government. Efforts to mobilize social action against elder abuse at a national level and to develop legislation and other policy initiatives have, however, so far met with mixed success. While elder abuse has been trumpeted by some claims-makers as a major new form of family violence, the absence of a strong elder lobby group and the absence of developed ideologies (e.g., feminism in the case of wife abuse and child sexual abuse) have resulted in elder abuse receiving much less attention than other problems grouped under the family violence rubric. Indeed, most of the legislation that presently exists in Canada deals not with the abuse of the elderly as a class but with the provision of services to dependent, incompetent adults whether they are elderly or not.

The author analyzes the influences of race and class on the life chances of blacks by focusing on the health care of black elderly. Theories based on cultural, class, and racial forces are explained in the context of how each would be used to analyze the health care of older blacks. The lower health and socioeconomic statuses of older blacks compared with older whites are documented. The author argues that cultural factors are unable to explain those differences adequately, and that class factors such as the profit orientation of the medical care system, and race factors such as residential segregation and racial discrimination in the medical care system, both contribute to the disparities in medical care. Since proposals for a U.S. national health insurance or national health service fail to include race-conscious measures, the proposals will fail to eliminate existing racial disparities in the health and health care of the elderly.

The current political economy of aging focuses largely on the conditions of old people in Western industrialized societies. Thus it ignores more than half of the world's elderly—those residing in Third World countries. In the first part of this article the author examines aging trends in developing countries, considering recent approaches to addressing the deteriorating economic and social conditions that shape the lives of the elderly in these countries. In the second part, a feminist perspective is used to assess the implications of these demographic trends and development strategies for women in Third World countries. It is argued that policies that place primary responsibility for care of the elderly within families are as unjust in Third World societies as they are in industrialized nations.

Four Brazilian food and nutrition programs operating during some part of 1974–86 are evaluated for their effectiveness in curing or preventing infant and child malnutrition, including low birth weight when pregnant women were beneficiaries. Two programs distributed free food to identified clients: traditional commercial foods in one case and specially formulated supplements in the other. The other two programs subsidized four or more basic foodstuffs: one experiment quantitatively restricted a subsidy to identified families, and the other was unrestricted and open to all families patronizing certain shops. The programs were more effective at curing than at preventing malnutrition, and more effective at increasing weight than height. Many beneficiaries, even when initially underweight, showed no change, and some deteriorated despite the food transfer. Results were better after than during the first year of life, when deterioration is most likely. Donation programs including medical and educational components proved more effective than pure subsidies, showing that while poverty may be the chief cause of malnutrition, the problem should be seen as poor health rather than simply low food consumption. Evaluation also shows that programs were inefficient in transferring benefits, and that clients were deterred from participating by the costs of obtaining the food and its poor quality and small volume. Longer participation improved results, but more frequent participation in a given interval did not necessarily do so.

The Expanded Program on Immunization has made remarkable progress in raising coverage in developing countries. Countries have been urged to accelerate their programs, especially in urban areas. In Mozambique, as part of program acceleration, volunteers from grassroots organizations conducted door-to-door canvassing for the Program. Concurrently, the availability of immunization was increased in health centers and in outreach visits. By 1987, over 90 percent coverage for all vaccines was achieved in the capital, Maputo; two other cities doubled their immunization coverage to over SO percent fully immunized children, and rural areas of the pilot province achieved 60 percent coverage. Immunization costs were estimated in one city as $6.9 (U.S. dollars) per fully vaccinated child. Door-to-door canvassing accounted for more than 40 percent of personnel costs, and may have diverted attention from the quality of service in the health centers. In this article we outline the achievements and costs of door-to-door canvassing and discuss other strategies to raise coverage. The analysis of the need to balance the mobilization of demand with the capacity to respond is relevant to other countries in their efforts to develop sustainable immunization services.