// there is a trill of frisson at the boundaries of epidemiologic theory; that is, the place where epidemiology meets not just biology and statistics, but also history, anthropology, and physics / this blog is an exploration and conversation about how we think about epidemiology: put simply, the epistemology of epidemiology / it’s time to throw away the tired paradigms, take off our gumshoes, and go barefoot //
The US House of Representatives has a tradition of one-minute floor speeches, usually given at the beginning of the legislative day.
On 4 January 1996, I wrote this one-minute speech as part of an assignment for a health policy class I was taking at Johns Hopkins University, just before the end of the 1995-96 government shutdown. Republicans shut down the government over President Bill Clinton’s proposed budget. The shut down put government works on furlough and suspended “non-essential services.” The November shutdown suspended about 800,000 employees and the December-January shut down furloughed 284,000.
Once upon a time there was a house filled officials with. A good life they had. Trips to far-off places never would they have seen. Opinions they had, elections they wanted, and homeward they sped. “Welfare reform!” shouted they; “health care reform!” ranted they; and so it was.
Returned to they offices grand and said they their footsoldiers to: “write me a bill! Make it long, make it short, I do not care, but to it sign my name, and, above all, name it well: use words to dispel, ‘responsibility,’ ‘reform,’ ‘work,’ ‘family; these ring out well. The states with money grants blocked, let decide them to do what, and reform call it we will. To this cuts in funding attach, a billion out here, a billion out there, let them without do. Praised we will be for the dollars to save. Release workers all, for them we don’t need.
The officials’ full house stood tall the day through. They ranted they raved they held firm and fast. That night when dark it was they for the door ran, aiming for home their car keys in hand. They found to their shock no guards, no police, no one to clean, and locked the doors were. When outward they looked and focused they saw they the grim workers a thousand-fold deep and lined up on the street. Locked up they were and off were the lights and outside was silence as deep as the night.
A child is born in an utterly undemocratic way. He cannot choose his mother or father. He cannot pick his sex or color, his religion, nationality or homeland. Whether he is born in a manor or a manger, whether he comes, closed-fisted, into the world, his fate – to a large extent – is decided by his nation’s leaders. It is they who decide whether he lives in comfort or in despair, in security or in fear. His fate is given to us to resolve – to the governments of the countries, democratic or otherwise … (Prime Minister Yitzak Rabin (1922-1995) upon acceptance of the Nobel Peace Prize, Oslo, Norway, 10 December 1994.
The story of maternal and child health (MCH) is a story of how people from many disciplines – pediatrics, social work, epidemiology, nursing, and psychology – came together to create a science based on child hygiene and the basic idea of preventing infant and child mortality.
In this chapter, we use the principal example of infant mortality to describe MCH across time and place into what the famous historian Fernand Braudel has called “one indivisible whole.”1 This chapter brings together the historical threads and social underpinnings of public health to describe current MCH issues and to considerhow the field can move forward to continue improving the health of women, children, and families globally through traditional public health measures as well as social equity and alleviation of poverty. The reader will be struck early on by the continuity that marks the evolution of MCH. Indeed, many areas of investigation that today’s students often think are new – like the principles of social epidemiology – were actually among the earliest ideas embedded in MCH.
Today we have new tools – high-tech neonatal intensive care units, vast public awareness campaigns, desktop computers capable of cutting-edge multivariable analyses and geographic data mapping, and sophisticated genetic research – but one is struck nonetheless by the seeming intractability of the world’s poverty, even in the developed world, and the impact on infant and maternal mortality. Public health practitioners interested in the welfare of mothers and their children are, as in decades past, interested in encouraging breastfeeding, dental hygiene, preventing infectious disease, and promoting vaccination. Indeed, this continuity can be understood as a theme to help us reflect on how MCH should address the problems of the future in both the developed and developing worlds.
Background and History of MCH
MCH has long been considered a core component of public health. Former dean of the University of Michigan School of Public Health, Dr. Myron Wegman (1908-2004), has explained that MCH emerged in 19th century Europe in part because following the end of the Franco-Prussian War in 1870, the French realized that population changes favored a
newly united German nation.2 French military leaders understood that creation of a strong army had to begin with healthy pregnancies and fewer infant deaths. In her treatise on the evolution of MCH in Europe and the United States, Alisa Klaus3 used a fable from Aesop to illustrate the French perspective, in which the fox derides the lion for having so few children. The lion’s reply is simple: “but every child is a lion.” Like Wegman, Klaus examines the idea that the French were pronatalist because of a national preoccupation with German militarism, which she contrasts with other approaches in Europe and North America to MCH that focused more on maternal welfare and infant nutrition.
For much of human history, children have worked, helping their families and villages meet daily agricultural, household, and survival needs; however, the European and American industrial revolutions of the 19th century meant that young children went to work in very public places, not just on farms.4 En masse, families migrated from rural areas into European cities and across the Atlantic into American cities, where they often lived in poverty, with poor sanitation and crowded housing. Urban living made the conditions of poverty more visible and improved birth registration meant that infant and child mortality rates were more obvious. These concerns, combined with the needs expressed by the French and other militaries, gave what Margolis and Kotch call a “convergence of social, economic, and political forces,” leading to the development of charitable movements and government-run health and social programs.4
Outside Europe and the United States, the history of MCH is less well documented. Consequently, we know far less about population health and policy influences on MCH in developing nations. The infrastructures of many current nations in Asia and Africa were built on and defined by decades and even centuries of colonialism. Native and indigenous people, lands, and resources were often subjugated and subverted for capitalist gain in Europe, North America, and China. In Africa, black majority populations worked for white minorities; in Asia, European, American, and Chinese merchants controlled a vast opium market; on the Asian subcontinent, British rulers and companies held control through economic and military force.
Coovadia and colleagues5 point out that these histories have had a profound effect on current population health, noting that in South Africa political, economic, and land restriction policies left a society structured according to hierarchies that have defined the current burden of disease. In India, the national Maternal and Child Welfare Bureau oversaw the improvement of maternity services and the training of rural midwives and birth attendants in the early 1900s; however, most work was voluntary and coordinated by the Indian Red Cross Society.6 In much of the developing world, the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF) , the US Centers for Disease Control and Prevention (CDC) and Agency for International Development (USAID), the European Union, and other international and non-governmental organizations were created in the twentieth century to fill leadership and funding gaps in MCH. The emergence of many non-governmental organizations, funded by international organizations like UNICEF or private donors, has helped numerous small causes, but has also led to fractured systems with poor inter-organizational communication and little institutionalization.
In fact, the legacy of colonialism and conflict in Africa and Asia, including economic and leadership changes in the former Soviet states, conflict in the Caucuses and Balkans, is still reflected in high rates of infant and maternal mortality and morbidity, epidemics like HIV/AIDs, infectious disease outbreaks, occupational and other hazards, and deleterious environmental conditions that impact health throughout the lifespan and lower life expectancy overall.
In this chapter, it is emphasized that the MCH data from the early twentieth century mirrors what we observe today in the developing world – very high infant and child mortality rates and high maternal mortality ratios in those same countries. These problems are exacerbated by the simultaneous emergence of non-communicable diseases like diabetes and cardiovascular disease. We argue that many of the same public health approaches that worked to drastically reduce infant, child, and maternal mortality rates in the developed world during the twentieth century are the same fundamental public health methods that can be deployed in the developing world to achieve similar results. Indeed, a systematic public health problem-solving approach, beginning with good vital statistics data collection and following with improved hygiene, water sanitation, breastfeeding, and good governance can be applied, based on needs and resources, on a region-by-region basis, dependent upon needs, to achieve much improved maternal and child health. improved maternal and child health.
Braudel F. On History. Chicago: University of Chicago Press; 1982.
Wegman M. Infant Mortality in the 20th Century, Dramatic but Uneven Progress: Symposium: Accomplishments in Child Nutrition during the 20th Century, Experimental Biology 2000, April 15-19, 2000, San Diego, CA. J Nutr. 2001;131:401S-408S.
Klaus A. Every Child a Lion: The Origins of Maternal and Infant Health Policy in the United States and France, 1890-1920. Ithaca, NY: Cornell University Press; 1993.
Margolis L, Kotch J. Tracing the historical foundations of maternal and child health to contemporary times. In: Maternal and Child Health: Programs, Problems, and Policy in Public Health. Third Edit. Boston: Jones and Bartlett Publishers; 2012.
Coovadia H, Jewkes R, Barron P, Sanders D, Mcintyre D. The health and health system of South Africa: historical roots of current public health challenges. Lancet. 2009;374:817-834. doi:10.1016/S0140.
Singh S. Maternal and child health services in India — past, present and future. Indian J Matern Child Heal. 1997;8(1):1-4.
A study in March 2015 conducted by King Edward Medical University, Lahore confirmed CHIKV prevalence amongst patients suspected to have acquired Dengue Fever in Lahore, Punjab. Not many cases were found in that study but those found warned the authorities to keep a high index of suspicion for Chikungunya in Pakistan. A study in 1983 also confirms high over-all prevalence rates of certain mosquito-borne diseases that included Chikungunya, Zika, Dengue etc.
Despite no reports of Chikungunya cases before in Pakistan, it was too early to claim its origin from India as claimed earlier in an article published by Tribune. Even though a number of cases has been reported in Delhi the previous year, there is no doubt that both countries share same climatic, geographical conditions and have fragile health infrastructure that cannot effectively diagnose and treat patients infected with such arboviruses. There are chances that mosquito borne diseases can be imported from…