Chapter One
INTRODUCTION
Demographers and the Health Transition
Many societies around the world are in the midst of a transition in child health. This transition is characterized by a move from high to low mortality accompanied by an epidemiological shift in the nature of illness from infectious to non-infectious diseases.
In this health transition, the World Health Organization has focused on the control of immuno-preventable disease and the reduction of deaths from diarrheal diseases. (WHO, 1990). Control and eventual elimination of these immuno-preventible diseases is becoming possible through mass immunization campaigns. Smallpox was eliminated from the world in 1979. Polio and measles are the next likely targets. Reduction in diarrheal deaths through campaigns aimed at distribution of oral rehydration salts has been the second major focus.
In addition to these modern medical interventions, there are also non-medical processes at work in this health transition. These reflect the adoption of new behaviors and attitudes associated with the social and economic modernization of these societies. Foremost among these are changes associated with increases in the standard of living such as improved nutrition and improved water and sanitiation. Other examples are reductions in family size and expansion of educational systems.
What is the role of demographers in understanding this health transition? The demographic study of mortality dates back to John Graunt (1662). His insight stemmed from an analysis of a large collection of mortality records, the London Bills Of Mortality. By examining these data, he was able to see what London doctors could not see -- patterns discernible at the population level.
More than three centuries later, the insight demographers bring to the study of this health transition is the same. Demographers can observe patterns in large collections of data -- patterns which may not be obvious to the medical personnel "on the ground" for various reasons. First, their observations are limited to a small number of children in a particular location and time. Second, their observations are biased because they see sick children but not healthy children. Third, the nature of their explanation for health improvements will tend to focus on the medical services they are providing rather than non-medical processes.
By using large scale surveys, demographers can make two contributions toward understanding this health transition. First, demographic techniques allow assessment of levels and trends in child mortality through survey data. Such techniques are especially valuable in societies in which accurate registries for vital events do not exist. These have provided our most reliable estimates of what has been happening during this health transition. (Palloni, 1991).
Second, we can observe patterns in behaviors and health outcomes at the population level. Such associations have revealed certain worldwide patterns: maternal education and long birth intervals are strongly associated with improved child survival (Cleland and van Ginneken, 1989; Hobcraft, McDonald, and Rutstein, 1985). Should such association prove to be causal, demographers will have identified important non-medical means for mortality reduction.
Child Malnutrition and Mortality in Bolivia
This dissertation assesses the health transition in Bolivia -- examining malnutrition and mortality among Bolivian children in the late 1980s and changes in their mortality before this period. Bolivia is one of the poorest countries in the Western Hemisphere with a GNP per capita of $630. (World Bank, 1992). Its geography and ethnic composition also make Bolivia unique among the Americas. Most of the Altiplano, a high plateau formed between the eastern and western mountain ranges of the Andes, lies in Bolivia. Almost half of Bolivia's population lives in this high-altitude environment. Bolivia is also the only country in the Americas in which the indigenous population is still a majority of the population.
A large-scale health survey, the Bolivian Demographic and Health Survey of 1989, will be used as the basis for the analysis. Between February and July of 1989, a total of 7,923 women were interviewed and physical measurements (height and weight) were taken on 2,682 children. The results of this dissertation will be presented in three analytic chapters. The first uses the DHS and other surveys to assess changes in mortality rates during the last 30 years. The second examines differentials in child height -- which is considered to be a measure of chronic malnutrition. The third examines differentials in neonatal and postneonatal mortality by cause of death.
Chapter Two begins with a brief introduction to the country of Bolivia: its geography, economy, culture, and demography. The second half of the chapter introduces the data set which is used in this analysis.
Chapter Three examines data on the health of Bolivian children from 1960 to 1990. Part One reviews various data sources on child health. Brass and Feeney techniques are applied to surveys to yield estimates of levels and trends in child mortality. Part Two reviews the macro-level evidence for explanations of the trend in child mortality.
Chapter Four presents a multivariate regression analysis to assess the determinants of stunting among Bolivian children. One key determinant of stunting, high-altitude hypoxia, is unmeasured in the DHS Bolivia. A new data set is created which links elevation data to the DHS to enable examination of this effect. Another key determinant, ethnicity, appears to be inadequately measured in the DHS. An imputation technique is used to provide better estimates of ethnicity using data from the Bolivian National Population and Housing Survey of 1988.
Chapter Five presents estimates of the socio-economic differentials in child mortality. A proximate determinants framework is used to assess the bio-medical factors which underlie these associations. Neonatal and post-neonatal mortality are examined by cause of death using multinomial logistic regression.
Finally, Chapter 6 presents a summary and discussion of the chief results of the dissertation and suggestions for further research.