Meilinomics II: Income from Within

The following is another excerpt from Dr. Ryan Meili’s new book, A Healthy Society: How a Focus on Health Can Revive Canadian Democracy, which fellow blogger Greg Fingas has been discussing.

The road to Tevele is red sand and sloppy in the rainy season. The pick- up truck bounces in and out of ruts as we head thirty-some kilometres from Massinga to this out-of-the-way rural community, located between the ocean and Mozambique’s national highway. I am travelling with Dr. Gerri Dickson, director of the Centre for Continuing Education in Health, and two teachers from that institution: Cipriano and Flávia, both of whom studied in Saskatoon as part of their teacher training.

The Centre for Continuing Education in Health has a long relationship with Tevele. The núcleo, a group of leaders selected by the various surrounding communities, meets regularly with staff and students from the centre to address the health needs of the people of Tevele. Over the years, they have selected malaria and HIV/AIDS as areas of focus, and have done various public education campaigns and research projects to try to improve prevention and access to treatment.

Núcleo members, many of them quite elderly, walk for miles to attend the meetings. While waiting for those who are late to arrive, we huddle around a fire built in a hollowed-out section of a large tree to take off the morning chill. After morning tea, a group of keen participants starts a raucous gathering song: “a kama wasiya” (time is running out). It’s a classic, well known by the members, and people clap and dance, animating the meeting grounds.

Like the centre, I also have a long relationship with Tevele. On each of my previous visits to Mozambique, I’ve taken time away from clinical work at the hospital to learn more about working with communities to improve health. The members of the núcleo are now old friends, and each visit feels like a family reunion. In 2007, I spent an extra week in the community, holding clinics and trying to improve my grasp of Xitswa, the local language.

The visitors and núcleo members gather under a large mango tree to start the day’s session. The sun comes out and warms us to the point of leaving our jackets in the back of the pick-up. Part of the opening of every meeting is the singing of the national anthem: Moçambique, Nossa Terra Gloriosa, an event that is taken very seriously. Everyone stands at attention, looks straight ahead and sings in a sombre voice. Passersby on the road to town stop and stand until the song is over. This time, halfway through the second chorus, the rain starts anew. This is no drizzle; it’s a tropical, soak- to-the-skin-in-seconds downpour. Given the solemnity of the song, no one can run and seek shelter. We grin and bear it, watering pouring down our faces as we finish the final lines of the anthem, then run into the newly built community development centre to start our meeting. While the topic is, as always, the health of the community of Tevele, today we aren’t talking about malaria and mosquitoes. We’re talking about money.

The most important determinant of health, much more than access to health care, genetics, or culture, is income. The members of the Tevele health núcleo may not have read the latest research on the social determinants of health, but they see every day the way in which the amount of money people have access to shapes their wellbeing and longevity. Every one of them has lost friends and family members to preventable and treatable illnesses like malaria, HIV, and malnutrition. They see how it is the poorest families that suffer the most, see how for the want of a few meticais a child dies at home rather than reaching the hospital for treatment. One of the younger núcleo members, Senhor Ronaldo, has not been feeling well lately. He has been losing weight and having frequent minor illnesses. His wife had left for South Africa a few years ago and last year she returned. She died a few months later. Many people from the area go to South Africa for work in the mines and other industries there. Coming home sick from South Africa has become synonymous with AIDS. Ronaldo has worked with the núcleo, educating local communities about HIV/AIDS and other sexually transmitted illnesses. He knows very well he should be tested and start treatment if positive, he knows that both testing and treatment are free of charge, but despite that knowledge, he still hasn’t gone for testing. This is not procrastination; he simply can’t afford the 50 meticais (about $2 CDN) to make the trip in one of the battered Toyota pickups that go regularly to Massinga. If he had some form of income beyond what he can grow on his machamba (small farm cultivated by hand) he would be able to access the care he needs. If there were more local income opportunities, perhaps his wife wouldn’t have had to leave for South Africa to make money.

Recognizing how important local sources of income are for their families and their community, the núcleo members have embarked on a program of economic development. With the help of Canadian partners and a group of young people called Zambo ni Zambo (Xitswa for step by step), they have begun a machamba and a carpentry work shop and have recently started to raise chickens. With help from CIDA (the Canadian Internation- al Development Agency), they have built a new “centre of competencies” for meetings related to the economic projects and storage of related materials. Proceeds from the project go to a common account to continue development, with a portion going to individuals involved, depending on the work they contribute. Zambo ni Zambo also works with another of the centre’s partner communities, Basso, on a sewing project and a bakery. The underlying idea is to increase the capacity of the community to sustain itself economically. This allows local people to have more access to gainful employment and income for necessities such as travel for hospital care and medications, simple household goods like blankets, and more varied food than what they can grow themselves. It allows them to find this income closer to home, decreasing the disruption to family life and community health brought by migrant work. This goes step-by-step with the health promotion and disease prevention activities of the núcleo, as rather than waiting for help from outside, the people of Tevele start to take charge of their own development. In the long run, these efforts may prove to be what makes a real difference, helping people like Senhor Ronaldo and his family to do better economically and live healthier, longer lives as a result.

Stories like that of Senhor Ronaldo’s bring home just how important economic opportunities are for health. From Mozambique to Canada and everywhere in between, economics is the primary practical human activity. The exchange of goods and services governs much of our everyday life. The economic success of individuals has the greatest influence on their health, far above biology, access to health services, or culture. That success is also a significant source of social stature.

I mentioned earlier that health care is always at or near the top of the list of public priorities. Its main opponent in vying for public concern is the economy. People recognize how important economic success is for physical, mental, and social wellbeing. The list of determinants of health is topped by income and social status, with the position in the economic hierarchy being the single largest factor affecting health. Income also determines many of the other determinants: the ability to afford child care or higher education, safe housing and good nutrition, leisure and exercise, and in many places access to health services. It is little surprise, then, that those at the top of the scale for wealth are there for health as well.

Nor is it surprising that economic success, such a key tool for reaching our goal of health and wellbeing, can get mistaken for the goal itself. This is a dangerous mistake. When a tool for reaching our goals gets confused with the goals themselves, we lose sight of the end and chase the means. Our political structures seek not to improve economies in order to improve our lives, but simply to improve economies regardless of the effect on people. In this sort of environment, measures of aggregate success such as GDP growth, rather than finer-tuned tools directed to true wellbeing, are used to measure our success as a society. And in such an environment, where the inequality of the distribution of ill health and poverty is not considered, a small number of people may grow very wealthy and well while a far greater number languish.

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