DISEASE AND RURAL DEVELOPMENT: A SOCIOLOGICAL ANALYSIS OF MORBIDITY IN TWO MEXICAN VILLAGES Asa Cristina Laurell, Josh Blanco Gil, Teresa Machetto, Juan Palomo, Claudia Perez Rulfo, Manuel Ruiz de Chlvez, Manuel Urbina, and Nora Velizquez It is suggested that the problem of the social causes of disease should be analyzed on the basis of the significant social processes of a given society. In this theoretical framework, a comparative study of two Mexican rural villages at different degrees of development is presented in order to clarify two related questions: what is the impact on morbidity of the rural development process, and what is the influence of socioeconomic conditions on the distribution of disease in the population? It was found that morbidity was significantly higher in the more “developed” village than in the one characterized by a predominantly subsistence economy. This finding is ascribed to the character of Mexican rural development, similar to that of other subordinated countries, which implies a change from subsistence agriculture to cashcrops in an unstable market, a massive conversion of peasants into wage laborers with unstable employment, and substantial migration; these phenomena give rise to new, unfavorable living and working conditions for large parts of the rural population. It is argued that it is not development as such that is responsible for the increase in morbidity, but the particular form that it assumes in the dependent countries. It was also found that socioeconomic characteristics such as people’s position in production, the sector of economic activity, and migration patterns defme groups of high and low morbidity more clearly than do sanitary conditions and access to professional medical care. These results suggest that the success of public health activities depends on the possibility to plan the process of change.

The general problem that is being addressed in this study is that of the social causation of disease. As we have pointed out in another paper (l), there are many studies (2-6) that demonstrate arelationship between various socioeconomic variables and the morbidity and mortality of a population. The characteristics of this relationship, however, have not been clearly specified. In our opinion, this is due to the fact that the problem has been insufficiently conceptualized. The usual procedure has been to study some indicators of economic, cultural, and health conditions in order to detect concomitant variations between them, frequently selecting the variables in a rather arbitrary manner (7). This method has two main weaknesses. On the one hand, The interpretation and analysis of the data are the responsibility of the primary author, Dr. Laureu. International Journal of Health Services, Volume 7, Number 3,1977 0 1977. Baywood Publishing Co.. h e .

401 doi: 10.2190/Q7AR-X9V1-KMV3-PCBX http://baywood.com

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it reduces a system of complex interrelationships to simple variables that do not allow an understanding of all the social dimensions in their totality. On the other hand, the indicators are assigned a value in themselves that they do not have because one and the same indicator can express different social phenomena depending on the entirety of the social relationships inherent in a historically defined society. We propose that the conceptualization of the social causality of disease should be based on the specific historical patterns of a society, establishing which are its critical processes, and what their consequences are for health and disease. It should be the analysis of these processes that determines the selection of the quantitative variables or indicators. This is the only way to establish an interpretative framework that will allow for a full comprehension of the phenomenon under discussion. It might be argued that this method would particularize knowledge to such an extent as to make it impossible to reach conclusions of a general and therefore scientific character. We do not think that this is the case, however. Through an analysis of the particular processes that are central to global social dynamics, it is possible to establish their general applicability, because one can in this manner avoid formalistic definitions that obscure the real content of things; for the same reason, it is possible to define basic categories that may assume very distinct concrete forms. To say that the causes of disease are social implies affirming that the actual and dynamic social structure expresses itself in a particular health situation, and that transformations of the latter bring about changes in the former. The second problem that has to be dealt with regarding the social causality of disease refers to the specific weight of social and biological aspects in the process of disease generation. We consider it necessary to distinguish two different levels. Undoubtedly biological factors have an important impact at the individual level regardless of socioeconomic status. Nonetheless, socioeconomic determinants assume decisive importance in relation to the social group and for collective health, and the relative weight of the social factors-with their strictly socioeconomic and environmental-ecological dimensions-is greater than that of the biological factors. The sociological analysis of health and disease is therefore useful above all when the unit of study is the social group and not the individual. Finally, we will make some reference to the concept of causality. We do not intend to establish that socioeconomic conditions are direct causal agents, although they might be so in some cases, but that they interact so as to determine the structure that unleashes and transforms the biological phenomena. There exists, thus, a multiple causality of disease in which the social aspects are necessary and determinant, but not sufficient. We look, then, in this framework for certain laws of the social causality of health and disease with the purpose of contributing to public health theory and practice. The theoretical position of our study can be summarized as follows: the economic structure and the social relations of production and exchange present in a society, and not the biological phenomena by themselves, determine the character of the relationship between man and nature and, consequently, the type of pathology afflicting him.

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FRAMEWORK OF THE STUDY Within this conceptual framework, this study intends to explain some particular situations. First, we want to elucidate the effect on health of the process of capitalist development as it appears in the rural areas of Mexico today. A similar approach was taken by Hughes and Hunter in Africa (8). These authors demonstrate that the type of development that has occurred there has provoked and/or aggravated a number of health problems. This purely ecological focus, however, sidesteps the problem of the socioeconomic reality that underlies this process. We consider that the center of the problem is the degree to which commercial relationships of production and exchange have penetrated rural areas. These relationships disintegrate the rural subsistence economy, transform the socioeconomic structure of the countryside, and integrate the rural working classes into new conditions of subordination. The process assumes different forms and is expressed in diverse relationships. In some parts, it is very intensive and fast, and in others weak and slow, but no area escapes it completely. (For an analysis of the Mexican agrarian structure and peasantry, see references 9-12.) The key aspects for an analysis of this process in relation to health and disease of the rural population are: (a) the amount and quality of available land; (b) the control exercised over it and the type of crops; (c) the extent of wage labor; and (d) the terms and the degree of importance of commercial exchanges. Access to land is present in three main forms, i.e. through private property, usufruct in the communal or ejido form, or by paying a rent in money, kind, or work. For various historical reasons, small landed property and ejido minifundistas constitute very extensive forms of land tenure in Mexico, and they have not disappeared despite the expansion of big capitalist agricultural enterprises. The fact that small direct producers have managed to preserve their legal rights to the land, however, does not necessarily imply that they also control the conditions of production. As a matter of fact, land use is determined by more or less alien decisions. This is so for various reasons: credit-both government and usurious, i.e. by private money lenders whose interest rates are not subject to control-is dependent on certain types of crops; there are laws that require the planting of special crops; the commercial exploitation of the product is controlled by nonpeasant groups. The loss of control over the use and the product of the land, together with the need for cash in order to acquire basic goods that are not now being produced locally, tend to monetize the rural economy. This is the context of wage labor in the rural areas of Mexico. Although it is true in general terms that the private or ejidal minijimdio has survived, this does not preclude that a part of the peasantry has lost its land and is obliged to subsist as wage labor. Another important fact, linked to demographic growth and the transformation of subsistence into commercial agriculture, is that the pressure on land has increased. The original parcel of land, by itself very small, can no longer be subdivided in order to supply the sons of the peasants with land. Also, commercial agriculture does not have the capacity of subsistence agriculture to absorb family labor on a regular basis. The sons of the peasants, therefore, find themselves obliged to look for other sources

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of income, utilizing their only resource: labor power. When they cannot find work in their villages, they emigrate to the urban centers or to areas of greater demand for workers. The landless rural population is not the only one that has to have recourse to wage labor. The minifundistas, immersed in a monetary economy, find themselves increasingly obliged to supplement their income as day laborers, whether in order to obtain manufactured goods, pay debts, or subsist during the months prior to the harvest. The wages paid in the rural areas are very much below those of the urban centers. Work is also irregular, as it is conditioned by the cyclical variations in the need for workers in agricultural production, which causes considerable periodic unemployment. The rural proletariat does not have access to the social security system and lacks trade unions, because the majority works for different employers and without regular contracts. In a subsistence economy, on the other hand, the division of labor is not very developed. Each family group produces the majority of the goods it consumes, and with few exceptions, the rest can be obtained within the community by barter. The role of money is not particularly important. However, the rural economy is being transformed as the result of a process whose dynamic centers are to be found outside the rural community, although the latter is being utilized in the development of this process. Through many mechanisms, the peasants are obliged to specialize their product in order to convert an increasingly larger part into money, while at the same time local self-sufficiency tends to disappear. It is in this commercial exchange that the peasant is most seriously affected. As a rule, agricultural products are sold in the market at a lower price than industrial ones. The small direct producer usually receives even less because he has to sell his products to intermediaries. It is evident, therefore, that the peasant lacks the means to influence the price of his product, which is set in the national or even the international market. The rural population, both small producers and day laborers, has to buy processed and manufactured products at a relatively higher price, which contributes to the deterioration of their living conditions. The rural sector also is the one most affected by the inflationary processes of recent years. The economic and social transformations inherent in this kind of development manifest themselves in important changes in the living conditions of the rural working classes that should be reflected in their health. In summary, Land ceases to be a direct opportunity for the production of the family’s food, to be converted into a means for obtaining money for the satisfaction of the socially determined basic necessities. The changes in agricultural techniques imply important ecological changes and displace the labor force. Wage labor as well as commercial agriculture bring about new divisions of labor and social relations of production and exchange, with profound consequences for the organization of the primary producer groups and the community as such. Internal differentiation becomes the determinant element in village organization.

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The dependency on money means, on the one hand, that the satisfaction of basic needs depends more on the socioeconomic position of the group than on its use of natural resources and, on the other hand, implies important changes in consumption patterns. The increasing social division of labor precludes local production of many goods, and this expresses itself in periodic unemployment, because people cannot work other than in agricultural production which, due to its character, does not guarantee a stable level of employment. The migratory movements imply that large groups break away socially and ecologically from their native environment and migrate to other sites that guarantee neither work nor favorable living conditions. These considerations concerning the character of rural development, in conjunction with the theoretical premise that sociomedical problems should be considered on the basis of socioeconomic and not restricted to paticular biological conditions (13), lead us to formulate two general complementary hypotheses: A rural population living largely within a subsistence economy presents a different pattern of morbidity than a population characterized by a greater degree of capitalist development. Socioeconomic and cultural characteristics, e.g. type of productive activity, economic surplus, transfer mechanisms, migratory status, family organization, nutritional habits, have a greater influence on morbidity than those characteristics generally referred to as environmental, e .g. housing, water quality, sanitary installations, and those related to medical care resources. METHODS The examination of the first hypothesis represents a methodological problem because the kind of process whose results on health we wish to study occurs over a long time span. Ideally, one should follow the population going through this process longitudinally and register their changes in health as socioeconomic changes occur. This was not feasible, and another procedure was chosen, i.e. the comparison of two rural villages at different degrees of development.

Selection of the Villages For practical reasons it was decided to study two communities situated in the same region of Mexico, both of them equipped with a rural health center. The villages chosen were to have a population of around 2500 and a similar demographic structure. The intention was to design the study in such a manner as to control for variations in morbidity due to the demographic characteristics of age and sex. Twelve villages satisfied this prerequisite and from among them two communities were chosen that showed the greatest difference in their levels of development. In order to measure these degrees of development objectively and on the basis of reproducible criteria, Pozas’ typology (14) of rural communities was used.

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The information necessary to classify the two communities along these lines was obtained from persons familiar with them and from the Ninth National Mexican Census (1 5). This information was subsequently verified during the fieldwork. Table 1 presents a summary of the demographic and socioeconomic characteristics that were taken into account for the selection of the villages, as at the time of the fieldwork in 1973. Table 1 Demographic and socioeconomic characteristics of two Mexican villages (A and T), 1973 Village A Demographic characteristicsa Sex Female Male Age group (years) 0-14 15-44 45 and over Employed in wage laborb OnlyC Principally Secondarily Parent generation Land and its use Access (property, usufruct, or rented)b ~ a i cropb n Corn Commercial Systems of usurious credit and hoarding of crops, by intermediary sellersd b Principal crop use Family consumption Commercial Migratory movementsb Out-migration In-migration Family structureb Extended Nuclear

Village T

%

%

48.8 51.2

49.9 50.1

48.5 37.2 14.3

47.2 37.3 15.5

47.9 66.3 12.4 26.9

13.4 24.4 17.6 14.1

35.1

75.0

52.5 47.8

75.8 24.2

extensive

limited

24.4 75.5

51.6 48.4

50.6 47.0

14.7 23.3

21.8 78.2

33.3 66.7

‘Data from the population census. bData from the sample population.

“Only” and “principally” are overlapping categories. dData obtained independently by direct observation.

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As can be seen, we succeeded in selecting two communities that were almost identical in terms of demographic structure but quite different in terms of the socioeconomic aspects that were considered important in the light of our theoretical framework. In village A wage laborers are predominant, with only one-third having independent access to land, whether by ownership, usufruct, or rent. In village T, on the other hand, 75 percent of the population has this type of access to land, although wage labor is starting to become important. Also the kinds of agricultural products, their destination, and the reliance on usurious credit systems and the extent of hoarding by intermediary sellers who buy up crops differ substantially in the two communities. Furthermore, migration is very important in village A, but is present to a much lesser degree in village T. Finally, family structure, an aspect that is directly related to productive activity patterns, shows a considerable difference. It should be pointed out that the two villages do not represent opposite poles but rather different stages of a process affecting all rural areas of Mexico. It is the different manifestations of this process which permit a valid comparison. Also, even if it might seem superfluous, we would like to make explicit that the conceptualization used here is not in terms of poor and rich, which are static notions. What is interesting and crucial are the relationships characterizing the activity that creates and transforms the major asset of man, his work.

Data Collection Commmity Study. Several of the aspects that are relevant to the present study cannot be reduced to variables that are directly measurable by a questionnaire. From the considerations presented in the introduction concerning the incorrect utilization of indicators, it is clear that it is necessary to study the overall dynamics of the two communities, i.e. in order to explain particular phenomena, it is essential to understand both the internal and external relationships of the communities. This is particularly important because of the fact that most sets of commonly used sociomedical and economic indicators are prefabricated, as it were, in industrial countries and cannot be equally applied in underdeveloped nations because of the different social structures involved. The 1973 community study thus was carried out according to preestablished guidelines that included those aspects considered important (16). The techniques of information gathering used were the focused interview, participatory observation, and the review of relevant available data complemented by data from the socioeconomic questionnaire. It is important to note that without the community study thus implemented, and an understanding of its results in their totality, many of the particular findings would have remained unexplained. The Sample. Given the absence of information about the number of families and inhabitants in the villages and of reliable maps, the first step was to make a census. Each domestic group or household was given a number for identification, and a map was drawn locating each group. The census also served to inform all of the inhabitants about the study that was being initiated. The sample size was calculated from the

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census data, utilizing the household as the sampling unit. It was decided to study 13s households in each village, corresponding to 746 individuals in village T and 756 ,i village A. The sample was divided into four subsamples, each being studied for three to six months of the study period (February 1973January 1974).

The Questionnaire. Two kinds of questionnaires were utilized in the study: a socioeconomic one applied to the household or family and a morbidity schedule applied to the individual. The socioeconomic questionnaire included 56 variables and covered aspects of demography, migration, environmental sanitation, education, attitudes and behavior related to health, economy, and organization. The information was obtained through an interview with the head of each household. Almost all of the variables referred to facts, and not to opinions or attitudes. The information probably has a high degree of reliability because most of the questions could be verified by direct or indirect procedures. The most problematic variable was “income.” This is due to a variety of reasons, e.g. a large part of rural income is in kind and not in money, and it is unevenly distributed over the year. Also, there is resistance to provide full answers to outsiders because of former negative experiences. Nevertheless, other data in the questionnaire, such as the expenditure on food, the amount of available land, and the kind of crops planted, permitted verification and adjustment of the information given in relation to income. The overall percentage of nonresponses to the different parts of the socioeconomic questionnaire was 2.2 to 4.4 percent in village A and 4.4 to 5.6 percent in village T. The morbidity questionnaire elicited acute illnesses suffered during the two weeks that preceded the interview. It was applied for each member of the household unit over a period of three to six months, covering the morbidity episodes of the communities during one year, and yielding approximately 6000 observations of health status in each community. Other studies (17-20) have demonstrated the problems inherent in establishing levels of morbidity through interviews. In the present study, therefore, the following precautions were taken:

0

The recall period was limited to 14 days. The interview was conducted with the female head of the household, who has been shown to be usually the best informed person concerning health problems of the household. The health status of each member of the household was asked for by mentioning him or her by name. The symptoms of most current diseases were listed in the interview.

This type of interrogation probably eliminates the risk that minor illness will not be reported, although it is recognized that the basic problem concerning the subjective concepts of health and disease, which determine whether a condition is considered pathological or not, has not been resolved (21-24). However, mention and elicitation of the most common symptom complexes will tend to eliminate the risk that people consider a disease state, as for example diarrhea, as “normal” because of its high incidence.

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Two more considerations should be mentioned in this respect. First, it is necessary to point out that despite the presence of traditional concepts of disease (magic, cold-hot) the population surveyed is also familiar with the categories and concepts of formal medicine. Second, analysis of our primary data did not indicate that the social groups at the lowest educational and economic levels reported less disease than the groups with better living conditions. It appears, therefore, that important variations regarding the perception of disease either do not exist among the groups studied, or that such differential perceptions did not increase but rather decreased the differences between these groups. The percentage of nonresponses to the morbidity survey was 4 percent in village A and 3 percent in village T. RESULTS Comparison between the Communities The general morbidity prevalence rate found in village A, the more “developed” village, was 15.3 per 100 observations; in village T, the community retaining important features of a subsistence economy, the rate was 11.0. That is, during a period of two weeks, 15 out of 100 persons were sick in village A and 11 out of 100 in village T. This difference is statistically significant at the P < .001 level. Although it is not the purpose of this paper to analyze particular diseases, it is important to point out that the observed difference in morbidity is quantitative and not qualitative. Acute respiratory infections were predominant and amounted to 42.9 percent of the general morbidity rate in village A and 44.1 percent in village T. Diarrhea symptoms were next in importance, accounting for 17.5 percent in village A and 20.6 percent in village T, followed by other infectious diseases, which made up 6.4 percent of the total morbidity in village A and 5.5 percent in village T. Accidents were quite important in village A (8.0 percent of general morbidity) while they were less prominent in village T at 2.7 percent. Accordingly, four disease groups account for almost three-fourths of the morbidity in the two villages, and no other group surpasses 3.5 percent of total morbidity. To show that the higher general morbidity rate in village A is the result of the socioeconomic and environmental conditions, it is necessary to exclude two sources of intervening factors: the possibility that an epidemic was present during the study Period, and secondly, that there are different levels of disease perception. The first possibility was ruled out through a comparative analysis of the seasonal variation in different diseases in the two communities, leading to the conclusion that there was no outbreak of disease that could be considered an epidemic. The second problem is, as we have pointed out, much more difficult to solve. This aspect was contemplated in the research design which partly eliminated the subjective impressions of the interviewed person. On the other hand, we know that the people of village T do not consider themselves particularly healthy inasmuch as they frequently more positively than the individuals in village A to the question whether People fall ill a lot. Almost the same number of persons in the two villages did not express any opinion.

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c tern at ion ally established health indicators (25-27) do not suffice to explain the observed &fferences in morbidity inasmuch as housing conditions and access to potable waterand sewage systems are considerably worse in village T than in village A. village A h a a larger number of medical resources, since three physicians, as compared to one in village T, work there on a regular basis and 38.5 percent of its population has access to social security facilities, while there is no access to such services in village T. The educational level is somewhat higher in village A than in T, and village A, furthermore, has both a primary and a secondary school, while T has a primary school only. With regard to the economic indicators most extensively used in health indexes, i.e. promedian income and the percentage of the economically active population in agriculture, village A again demonstrates a more favorable situation than village T, with a promedian family income of 1345 pesos as compared to 1042 in T; the percentage of the economically active population in agriculture is 39 percent in village A and 87 percent in village T. Clearly, then, the simple application of these indicators does not explain higher morbidity rates in village A. We did in fact explore the possibility that, due to their being computed for the entire population, the indicators were possibly not representative; for instance, village A might contain one or more social groups whose characteristics were such as to distort the overall morbidity rate. Analysis of the morbidity of the different social groups in both villages showed that the only group in A that reported a general morbidity rate similar to that of T (1 1 .O per 100 observations) was the peasant group, i.e. those households which had some measure o f independent access to land. This group did not include agricultural workers. A grouping of the population by such criteria as education, environmental sanitation, behavior relative to medical care, migration, and income, on the other hand, did not establish any groups presenting morbidity rates similar to those observed in village T. Nor were there any groups with high enough morbidity rates to explain the excess of morbidity in village A. Morbidity and Environment

One of our hypotheses states that the socioeconomic dimension has a greater weight with regard to morbidity than the physicosocial one. Table 2, summarizing the data on sanitation and the corresponding morbidity rates, shows a different situation to prevail in the two communities. In village T, there is no clear tendency in the relation between morbidity and sanitation characteristics. In contrast, in village A those groups living in better environmental conditions as measured by these variables show lower general morbidity rates than the groups living in worse environmental conditions. In order to distinguish these environmental effects from the impact of socioeconomic variables, which could well determine both morbidity rates and environmental conditions, morbidity was also analyzed according to both environmental and socioeconomic characteristics. AS shown in Table 3, it can be seen that overall the four socioeconomic variables selected-position in production, migratory status, underemployment, and literacy-

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41 1

Table 2 General morbidity rates by characteristics of the physicosocial environment for villages A and T, 1973 Morbidity Rate per 100 Observations Characteristics of the Physicosocial Environment

Village A

Village T

Bad Satisfactory River or water hole Well Public system Other Inadequate Adequate Nonexistent Available

17.3 12.6 24.9 17.1 13.2 10.7* 17.5 12.0 16.6 13.6 15.3

10.7 12.1 11.4 8.8 11.4 16.6a 10.9 11.4 10.7 12.5 11.0

Housing

Source of water supply

Treatment of trash Sanitary installations Overall morbidity rate 'Based on small numbers.

have indeed considerable effect on morbidity rates and partly neutralize the effect of the environmental variables. The characteristic that most clearly distinguishes the groups in terms of morbidity is their position in production. Wage laborers show consistently higher morbidity rates than do proprietors (defined as all those having independent access to land, whether through ownership, usufruct, or rent) in the corresponding environmental groups, i.e. the rates of morbidity of the wage laborers are equal to or higher than those of the proprietors living in equally bad environmental conditions. The same situation exists in the comparison between in-migrants and non-migrants. Furthermore, in the group of in-migrants the effect of housing and of sanitary installations is totally nullified. The third variable, underemployment or temporary unemployment, also divides the population into groups with higher and lower morbidity, although the impact of the physicosocial environment does appear within the two groups. The level of schooling, as indicator for the literacy variable, was measured dividing the population into two groups: those in which both parents or spouses were illiterate and those in which at least one parent was literate. This variable does not have as clear a predictive value as the other three socioeconomic variables, and the data here even Seem to indicate that environmental factors have more importance with respect to morbidity than the level of schooling. This probably is explained by the relative value of literacy as a measure of knowledge, a problem that will be discussed later. It might be assumed that the observed impact of environmental conditions would increase if communicable diseases were to be isolated from general morbidity rates.

w

P

15.4 10.9 12.4

-’

14.5 9.9 13.5 11.1 12.2

19.6 14.2 18.4 16.4 17.8

15.3 9.6

32.5 21.5 14.0 12.26

19.4 15.4

Wage Laborer Proprietor‘

7.9’ 11.6 12.5 13.2 12.6 13.3 11.6 12.3

20.5 12.9 17.6 17.9 17.6

16.2 9.5

No

30.8 19.0 13.0 10.7b

17.9 17.7

Yes

In-migrant

27.9 14.5 13.2 12.26 10.6 12.8 16.9 13.5 15.0

19.4 9.4 17.0 15.1 16.7

‘Dash signifies no cases.

17.9 12.5

No

13.6 19.9 14.1 -

18.2 13.4

Yes

:Defined as all those having independent access to land, whether through ownership, usufruct, or rent. Based on small numbers.

Housing Bad Satisfactory Source of water supply River or water hole Well Public system Other Treatment of trash Inadequate Adequate Sanitary installations Nonexistent Available Mean morbidity rate

Characteristics of Physicosocial Environment

Position in Production

Periodic Unemployment during the Year

Socioeconomic Characteristics

7.36 23.9 13.0 18.4 10.7 18.1 10.1 17.2

17.2 12.4 16.3 13.6 14.0

17.1 25.0b

No

30.1 14.9 12.8 12.2

18.7 12.1

Yes

Literate

General morbidity rates per 100 observations by socioeconomic and environmental characteristics, village A, 1973

Table 3

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The analysis of acute respiratory disease and diarrheas did not confirm this assumption, however, but demonstrated the same distribution across the population as general morbidity. In summary, the socioeconomic variables themselves appear to have a direct impact on morbidity that is independent of environmental conditions. As a matter of fact, the socioeconomic conditions of a particular group influence the physicosocial environment in two ways: (a) socioeconomic status has a direct influence on factors such as the kind of housing, the possibility to acquire sanitary installations, and access to potable water (which frequently has to be bought); and (b) it modifies the effect of environmental conditions. Morbidity and Access to Medical Services

The second aspect that is given much importance in the determination of the health status of a population is their medical care resources. In order to evaluate the effect of existing access to medical services, we calculated the morbidity rates of the two study populations by the kind of medical services available and the person providing them. The results are shown in Table 4, which reveals the striking observation that the population with social and economic access to the different available forms of formal medical services does not exhibit a general morbidity rate that is significantly lower than that found among the groups that are marginal to these services. The relatively higher morbidity that is observed in both communities for the groups utilizing the services of the rural health center must not remain without comment. The excess of morbidity in these groups is obviously not attributable to the services provided by these centers, but rather to the pattern of utilization of these government facilities. Table 4 General morbidity rates by access to medical services, villages A and T, 1973 Morbidity Rate per 100 Observations Practice Setting Person who attends the patient Physician Self care or nonprofessional Utilization of rural health center No Yes Utilization of social security health services

No Yes Overall morbiditv rate

Village A

Village T

14.8 15.8

11.9 10.8

12.3 18.1

9.9 13.3

15.3 15.2

15.3

‘Dash signifies not applicable, as population is not covered by social security.

11.0

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In both villages A and T, their patients are those sectors of the pOpUlatiOn that live in precarious economic conditions, with neither the ability to pay the fees of private physicians nor access to the social security systems, i.e. they are wage laborers with a low income, the temporarily unemployed, and the in-migrants. These data show that formal medical services as currently provided are not a critic4 factor for morbidity in the rural areas, a finding supporting the observations of Heredia Duarte (5,pp. 485-488) concerning mortality and medical care. Morbidity and Socioeconomic Conditions

After having studied the variables generally considered to be the most important for health and disease, i.e. environmental sanitation and medical care resources, and observing that they do not have a decisive influence on the distribution of disease in the population, it is necessary to analyze more thoroughly those socioeconomic variables that according to the postulated hypotheses determine the morbidity of human populations. Table 5 summarizes the morbidity rates that result from a classification of the population by selected socioeconomic criteria. In the two villages studied, three economic indicators have an important influence on morbidity: position in production, occupational sector, and underemployment or periodic unemployment. Thus, wage laborers report a significantly higher morbidity rate, 17.8 per 100 observations in village A and 13.1 in village T, than the proprietors as previously defined, who have rates of 12.2 and 10.7, respectively. The population belonging to households whose breadwinners are not employed continuously throughout the year are characterized by a higher rate of morbidity, and the difference between the underemployed and the rest of the population is more striking in village T than in village A. In both villages, agricultural workers exhibit high morbidity rates, while the rest of the population active in agriculture presents relatively low rates. The population employed in industry and services and commerce shows a different situation in A than in T, with high morbidity rates in the former and low rates in the latter, a fact that can be explained by the different economic structure of the two communities. In A, the people in industry and services and commerce are almost entirely wage laborers, while in T they belong almost exclusively (90 percent) to the petty bourgeoisie, i.e. they are owners of small commercial and service establishments and thus do not participate in the productive relationships of modem economy, but represent a traditional sector within the agrarian structure. The rest of the economic variables likewise demonstrate differences in the two villages in relation to morbidity. The position in production of the parental generation of the respondents appears to be very important in village A, but not in village T. We consider this difference due to the fact that proletarization is a mass phenomenon affecting the community as a whole in village A while in T it is a slow process that has had less influence both on the community as such and on the groups directly involved. The findings apparent from the relation between income and morbidity seem to be paradoxical. The only group in A that is distinct from the rest of the population in

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41 5

Table 5 General morbidity rates by selected socioeconomic characteristics, villages A and T, 1973 Morbidity Rate per 100 Observations' Socioeconomic Characteristics Position in production Wage laborer Propnetorb Position in production of parent generation Wage laborer Proprietorb Occupational sector Agricultural worker Others in agriculture Industry Services and commerce Periodic unemployment during the year Yes No Family income per month (pesos) 0-999 1000-1999 2000 or more Utilization of credit Yes No Main crop Corn Commercial Migratory status In-migrant Native Literate Yes No Family structure Nuclear Extended Overall morbidity rate

Village A 17.8 * 12.2

Village T 13.1* 10.7

21.9 13.4

*

10.6 10.9

19.1 11.0 26.4 14.0

*

15.1 10.7

16.7 15.0

*

{

8.1

13.2*

9.8

17.5 13.5 * 13.3

10.9 10.9 10.9

18.0 * 13.4

9.8 11.9

10.7 12.7

10.7* 8.2

17.6 12.3

11.4 10.9

*

10.6 12.8

16.3 * 10.4

11.2 9.9

15.3

11.0

14.9 17.2

'The rates are not always based on the same population because some of the variables are not applicable to the total sample. *Defined as all those having independent access to land, whether through ownership, usufruct, or rent. *Statistically significant at P < .05 (X2).

416 / Laurelletal. terms of morbidity rates is the one that has incomes of 1000 pesos or less, whereas in T not even this differentiation can be observed. These findings show that monetary income as such is not a good indicator of socioeconomic conditions for rural populations. The use of credit and the type of crops have a different influence on morbidity in the two villages. In village A the agricultural groups that rely on credit and work in commercial crops-two factors usually linked-report a higher morbidity rate than the rest of the peasant groups. Those are the groups that are captives of the usurious credit/crop hoarding/usurious credit cycle. That is, they participate in relations of production and exchange imposed on them by the development of capitalism in the Mexican countryside. The peasant is obliged to leave subsistence agriculture and enter commercial production under the conditions described previously, and these changes are reflected in his health. In village T, we find the inverse of this relationship; the population that does not employ such credit and produces corn-a noncommercial crop if planted on a small scale-is the one that shows the highest rates of morbidity, although these are not higher than in village A. While it might seem that this finding contradicts the previous argument, the contradiction is resolved if the phenomenon is analyzed within its context. As we have mentioned (see Table l), usurious credit systems and hoarding of crops are very limited in T. This means that they have not penetrated the mass of the rninifundista peasantry, but are restricted to the middlelevel farmers that need not rely on usurious loans but can obtain bank credit and have better possibilities for marketing their product without establishing relations of dependency with the speculator-hoarder. As can be seen, different phenomena prevail in the two villages that affect the health of the groups in a distinct manner. Again, the migratory situation is of great importance to health in A, while its influence is rather insignificant in T. This is likewise a phenomenon that has different implications in the two villages. As was already pointed out, in- and out-migration are of considerable relevance in A but not in T (see Table l), because of the different structure of the two villages. As a matter of fact, migration in A is so important as to be reflected in the physicosocial environment. In this village of 2500 persons there exist on a small scale what in the cities have been called cinturones de miseria or belts of misery, i.e. suburban slums. Apart from their adverse environmental situation, the in-migrants are restricted by a number of economic limitations: they have access neither to land nor to the well-paid stable jobs, so the vast majority are wage laborers and periodically unemployed. The relation between the level of schooling and health status is again difficult to interpret. We find that the only measurement that clearly,separates groups with different morbidity is when the two parents are illiterate in comparison with the groups in which at least one of the spouses knows how to write and read. No clear trend is apparent that allows US to confirm that with a higher education one suffers less disease or vice versa. In this case we are probably faced by a conceptual problem. The educational level variable is intended to measure knowledge, and the indicator ‘’years of schooling,” in the situation that we are studying, probably does not really measure knowledge. Traditional school education frequently does not provide the kind of knowledge the rural population needs to face their social or their natural environment.

Disease and Rural Development

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The final socioeconomic aspect that appeared to be important is family structure. In both communities, people living in extended families have a lower morbidity rate than those who live in nuclear families. Here, we should recall that the extended family exists where it constitutes the basic unit of production, and in the present case, this refers primarily to households engaged in subsistence agriculture. The extended family is based on the division of labor within the family and it has a greater capacity to absorb labor on a regular basis than does commercial agriculture. The morbidity differences observed for these two forms of family organization reflect, then, different economic activities. It is clear that the socioeconomic aspects studied are not independent of each other, but are related by causal associations and feedback mechanisms. Therefore, it is not possible to establish simple relations of cause and effect between the variables discussed and the level of morbidity. Nevertheless, one can distinguish indicators of greater or lesser weight with regard to health and illness, although we again point out that they are indicators of fairly complex situations and have validity only within specific socioeconomic dimensions. Tables 6 and 7 summarize the morbidity rates for both villages by groups determined by two sets of socioeconomic characteristics. In village A (Table 6) the traits that have particular influence on morbidity are position in production, migratory status, position in production of the paternal or preceding generation, and occupational sector. Those factors have the same tendency regarding the distribution of disease in each subgroup of the population. Literacy, income, and temporary unemployment, on the other hand, demonstrate an influence that is conditioned by other factors and are important for the group of wage laborers but not for the proprietors as previously defmed. The morbidity rates of the in-migrants are affected by income and underemployment but not by literacy, a factor which does affect the morbidity rates of those native to the village. As can be seen in Table 7, the conditions relating to the population in village T are surprisingly homogeneous in the sense that various variables coincide in one group. The wage laborers are at the same time the underemployed that earn the lowest wages and show the highest morbidity rates. This makes it difficult if not impossible to measure the relative effect of each indicator. Within the wage labor-underemployedlow income group, illiteracy contributes to elevated morbidity, but this is not true for the rest of the population.

DISCUSSION AND CONCLUSIONS The results of this study allow the confirmation of the two general hypotheses previously stated. Viage T, which depends on an economy which is still largely of the subsistence type, shows a lower general morbidity rate than village A, with a higher degree of capitalist development. The analysis of morbidity in relation to socioeconomic and environmental factors and to medical resources also confirms that the former are determinant for the distribution of disease in the population. These findings indicate that the changes implied by the type of development now occurring in the Mexican rural areas have a negative repercussion on health. We have

m

+

9.4 13.8 13.0 13.0 10.2 14.8 9.8

29.6 14.2 24.1 15.6 21.5 13.3 16.8 20.3 14.4

14.6 10.4

12.2

Proprietor'

11.0 16.9 13.7

19.1

24.1 14.6

17.8

Laborer

17.8 -

19.5 16.3 11.7

19.8 17.2

21.2 14.3 25.8 15.2

22.7 15.4

20.3 14.8

~

18.0 14.9

12.3 ~~~

16.0 26.8 -

20.2 14.5

24.7 10.9 16.0

32.1 10.3

21.3 11.4

18.0 12.1

18.4 13.1 13.3

12.6 15.7

14.1 11.4 28.1 13.8

18.2 13.6

16.4 12.7

No

Literate Yes

11.9 11.4 14.4

8.9 13.0

8.7b 8.7 27.5 13.0

19.8 11.0

14.4 9.3

No

In-migrant Yes

'Defined as all those having independent access to land, whether through ownership, usufruct, or rent. bRate based on small numbers. 'Dash signifies no cases.

Position in production Wage laborer Proprietor Position in production of parent generation Wage laborer Proprietor Occupational sector Agricultural worker Others in agriculture Industry Services and commerce Periodic unemployment during the year Yes No Monthly family income (pesos) 0-999 1000- 1999 2000 or more In-migrant Yes No

Socioeconomic Characteristics

Position in Production Wage

Rate per 100 Observations

General morbidity rates by selected socioeconomic characteristics, village A, 1973

Table 6

12.5 9.9 10.4 11.0 11.0

2.7’ 14.4 7.9’ 12.6 -

10.7

Proprietor‘

10.7 10.1

14.5

13.1

Wage Laborer

13.4 11.3’ -

13.2

15.4 12.9 2.6b

14.4 12.5

Yes

‘Defined as all those having independent access to land, whether through ownership, usufruct, or rent. ’Rate based on small numbers. Dash signifies no cases.

Position in production Wage laborer Proprietor‘ Occupational sector Agricultural worker Others in agriculture Industry Services and commerce Periodic unemployment during the year Yes No Monthly family income (pesos) 0-999 1000-1999 2000 or more

Socioeconomic Characteristics

Position in Production

8.2 11.0 11.0

9.8

10.8’ 9.8 9.5

7.9’ 9.9

No

Periodic Unemployment during the Year

Rate per 100 Observations

General morbidity rates by selected socioeconomic characteristics, village T, 1973

Table 7

13.1 10.9 15.4

14.8 10.7

13.2 9.5 10.4 10.6 11.6

17.5 11.5 -C

15.9 11.0

No

12.9 10.7 8.1

11.5 10.4

Yes

Literate

420

/

Laurel1 et al.

seen that the characteristics pointed out as typical of this development process (see Table 1) distinguish groups of higher and lower morbidity. In t h i s manner, the wage laborers in the two communities show higher morbidity rates than do the proprietors, On the other hand, the only group in A that shows the same rate as the one in T is the group that maintains a fundamental peasant characteristic, i.e. independent access to and a certain measure of control over land. As far as the migratory movement is concerned, we have demonstrated that migrant status has deep implications for health when it is a massive social phenomenon. But it would not be proper to isolate each variable and ascribe to it a specific effect on health. What we have tried to show throughout this paper is that the totality of socioeconomic relations in a specific social formation is reflected in the health of its different population groups. Village T is internally rather homogeneous and its external relations, although based on conditions of unequal exchange, are much less extensive than is true for village A. And the very maintenance of a degree of economic and social self-sufficiencyindicates a particular relationship to nature and to the rest of society. That is why the fact that the people of T belong to a relatively stable social and biological system is more decisive than are the differences inside that community. In this context, it is important to recall that particular characteristics of the environment, e.g. sanitary conditions, do not distinguish groups with different morbidity in village T (see Table 2). The total environment, then, is dominant. The differences in morbidity found between the various groups in T, which incidentally were never as great as in A, are related to socioeconomic characteristics. The process of differentiation regarding morbidity occurs first in relation to such socioeconomic conditions and not sanitary conditions. Village A, on the other hand, is strictly speaking no longer a community. It presents sharp internal divisions between groups. It is easy, then, to distinguish different social classes that have established internal and external relations of exploitation. This differentiation has become so important that for the people of A, class determines health conditions, and belonging to a given “community” is of secondary importance. The particular relation of each individual with nature varies according to his economic activity and his position in the productive process, which in turn depends on his relations with society as a whole. The most direct effect of the type of development under study is that it causes ecological disruption in the widest sense of the term. That is, it completely changes the relationship between man and nature. Even without having studied the accompanying biological transformations in the ecological systems-a study that would be of great interest-one can assume that commercial crops, grown intensively with fertilizers and insecticides, imply a series of transformations and imbalances. And it is not only the relations between man and nature that are being changed but also those that exist among men and social groups. A growing part of the population is irreversibly transformed into wage labor that sells its labor power under unfavorable conditions. They lack organization to establish their wage rates and are forced to buy the goods necessary for survival at comparatively high prices, since they themselves cannot produce them. Their estrangement from the soil also deprives them of the

Disease and Rural Development

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possibility of employing a series of vital survival strategies that the semi-self-sufficient peasantry has at its disposal. That part of the rural population that still cultivates the land has also established new relations with the rest of society. The change from subsistence to commercial crops under the circumstances described earlier implies that they exchange the product of their work for money and goods under conditions of inequality. Thus they, as well as the wage laborers, have to buy basic products. The process of development referred to here thus means for a large majority of the rural population a higher degree of dependence on society and less control over the conditions of their life and work. Although they might dispose of more money, all the goods necessary to life according to socially established norms are more expensive if measured by the quantity of work that has to be invested to get them. This commercialization is also reflected in the pattern of consumption. The introduction into the market of industrially manufactured goods, even though it may be marginal, carries with it a redefinition of social necessities influenced by commercial advertising as diffused by the mass media. The consequence of this is a new distribution of family income in terms of consumption. Food, for example, begins to include processed products that frequently are comparatively expensive and of low nutritional value. Thus, beer and soft drinks, for example, are consumed daily in the two communities studied. Even among families with very low incomes it is common to find that they are buying products on credit whose only value is that of status instead of those that can be considered, strictly speaking, to constitute basic necessities. The diversification in relations of production and exchange tends to disintegrate the rural community because the base of equality constituted by similar productive activity disappears, and this process takes place in conditions that frequently impede the formation of new groups with common interests. We believe that these are the factors which, seen in conjunction, translate into a worsening of the health situation among a rural population involved in the process of development. We would like to add to this two complementary observations. In the first place, it is necessary to emphasize once more that the findings of this study refer to a specific historical process of development. Development that implies different social and productive relationships need not lead to the same consequences, as has been shown in the cases of Cuba and China. There, the process of change, which in every way has been much more rapid in those two countries than in other underdeveloped nations, has not been accompanied by the same negative effects on health. Instead of mitigating against the findings of our study, we think this fact supports our arguments. The second observation refers to the differences in morbidity that were found, One could have expected these to be qualitative rather than quantitative, i.e. that pathologies qualitatively distinct should correspond to socioeconomic transformations. We would like to recall, however, that historically speaking, it is possible to distinguish two phases in the development of industrial, capitalist society as far as its impact on health is concerned. The first period shows an increase in existing problems, whereas

422

/ Laurellet al.

in the second period old problems tend to disappear and be replaced by new ones (28). Even village A is still far from presenting conditions of life and work typical of an industrial society. Furthermore, precisely because of the particular form of develop. merit jn the subordinated capitalist countries, it is unlikely that they will pass from one pathology to another. Rather one would expect to find a corresponding combha. tion of pathological symptoms as the manifestation of the unequal and subordinated character of their development. REFERENCES 1. Laurell, A. C., and Blanco Gi, I . Morbilidad, ambiente y organizacidn social: Un modelo te6rico para el anilisis de la enfermedad en el medio rural. Salud Ptiblica de Mkxico 17(4): 471-480,1975. 2. Antonovsky, A., and Zola, J. K., editors. Poverty and Health. Harvard University Press, Cambridge, Mass., 1969. 3. Antonovsky, A. Social class, life expectancy and overall mortality. Milbank Mem. Fund Q. 45(1): 37-75,1967. 4 . Behm, H. La Mortalidad Infantil y Nivel de Vida. Universidad de Chile, Santiago, 1962. 5 . Heredia Duarte, A. El increment0 de la mortalidad infantil en M6xico. Gaceta Midica Mexicana 103(6): 475-493,1972. 6. Mej(a Vanegas, A., Badgley, R. F., and Kasius, V. The Colombia, South America, National Health Survey. In The Community as an Epidemiological Laboratory, edited by J. J. Kessler and M. L. Levine, pp. 297-314. Johns Hopkins Press, Baltimore, 1970. 7. Stockwell, E. G. Socioeconomic status and mortality in the U.S. Publ. Health Rep. 76(12): 1081-1086,1961. 8. Hughes, C. C., and Hunter, J. M. Disease and “development” in Africa. In The Social Organization ofHealth, edited by H. Dreitzet, pp, 150-214. Macmillan, New York, 1971. , 9. Bartra, R. Campesinado y poder polihco en Mixico. ReuistaMexicana de Sociologia 35(3-4): 659684,1973. 10. Gutelmann, M. Riforme e t Mystification Agraire en Amtrique Latine-La cas de Mexique. F. Maspero, Paris, 1971. 11. Pozas, R. H., and de Pozas, I. Los Indios en las ClasesSocialesdeMdxico. Siglo XXI, Mexico, 1971. 12. Stavenhagen, R. Las Clases Sociales en las Sociedades Agranizs. Siglo XXI, Mexico, 1969. 13. Cassel, 3. Social sciencz theory as a SOUIC~ of hypotheses in epidemiological research. Am. J . Public Health 54(9): 1482-1488,1964. 14. Pozas, R. El Desarrollo de la Comunidad. Ed. 2. Universidad Nacional Autdnoma de Mixico, Mexico, 1964. 15. I X Censo General de Poblacidn. Secretar