Measuring Human Rights (22): When Can You Call Something a “Famine”?

With yet another famine in the Horn of Africa, perhaps it’s a good time for a few words about famine measurement.

People have a right to adequate nourishment and to be free from chronic hunger (see article 25 of the Universal Declaration). Starvation is an extreme form of violation of this right (and is obviously also a violation of the right to life). So we obviously want to know the existence and extent of cases of starvation. There are individual cases of starvation – a elderly person who has lost her mobility and social network may starve abandoned in her flat – but most cases involve large scale famines. Let’s focus on the latter.

The problem is that death by famine or starvation is difficult to identify. People suffering from extreme malnutrition often don’t die of hunger but of diseases provoked by malnutrition, such as pneumonia or diarrhea. Since those are diseases that can have other causes besides malnutrition, it’s often difficult to count the number of people who have died from malnutrition. Their body weight may tell us something, but you can’t go about weighing corpses on a large scale.

Hence it’s difficult to determine whether or not a famine has occurred or is occurring. When does widespread suffering of hunger become a famine? Not every food crisis or widespread occurrence of malnutrition leads to famine-type starvation. A famine is obviously characterized by mortality caused by malnutrition. So we must look at mortality rates, but given the difficulty of establishing whether deaths are caused by malnutrition or other factors, how do we decide that a certain mortality rate is caused by malnutrition and is therefore the symptom of a famine? It’s difficult.

And yet, it’s common to find newspaper reports about “an outbreak of famine” is this or other part of the world. Ideally, we only want to declare a famine when a famine is actually occurring or about to occur. False alarms are not only silly but they create indifference. Fortunately, people seem to have overcome some of the difficulties and have agreed on a non-arbitrary way to determine that there is a famine going on:

  • when overall mortality rates in a region are extremely high, or high compared to the baseline – which may itself be high already, perhaps because of a war (a mortality rate of at least two people per 10,000 per day is usually considered part of the evidence of famine conditions)
  • when this is combined with survey indicators about low food availability and malnutrition (a rate of malnutrition – ratio of weight to height – among children age six months to five years above an average of 30% is the usual measure here)
  • when there is anecdotal evidence (perhaps also from surveys)
  • and when there are proxy measures such as below average rainfall

then you can build a useful measurement and a more or less scientific way of ascertaining that a food crisis has passed the famine threshold.

None of this should be understood as implying that food crises which don’t reach the famine threshold are unimportant and don’t deserve attention or assistance. It only means that it’s a good thing to distinguish real famines from lesser crises and to avoid crying wolf.

One problem with the measurement system presented above is that it’s no help in preventing a famine. It’s difficult to turn it into a probability index rather than a threshold index. It tells you when a famine has occurred or is ongoing, not when there’s a risk of famine. When mortality rates are high, you’re already late, perhaps too late.

Measuring Human Rights (16): The Right to Healthcare

(There’s a more theoretical post here about the reasons why we should call health care a human right. But even if you think those are bad reasons, you may find the following useful).

The right to health care is one of the most difficult rights to measure. You can either try to measure people’s health directly and assume that good health means good health care, or you can measure the provision of health care and assume that there will be good health with a good health care system. Doing the latter means, for example:

  • measuring the number of health workers per capita for countries
  • measuring the quality of hospitals
  • measuring health care spending by governments
  • measuring the availability and affordability of health care
  • measuring the availability and affordability of health insurance
  • etc.

Doing the former means:

  • measuring life expectancy
  • measuring infant mortality
  • measuring maternal mortality
  • measuring calorie intake
  • measuring the incidence of certain diseases
  • measuring the survival rates for certain diseases
  • etc.

Needless to say that every single one of these measurements is fraught with problems, although some more so than others. Even if you’re able to have a pretty good measurement for a single indicator for a single country, it may be difficult to compare the measurement across countries. For example, health insurance is organized in so many different ways that it may be impossible to compare the level of insurance across different countries.

But let’s focus on another measure. Life expectancy is often used as a proxy for health. And indeed, when people live longer, on average, we can reasonably assume that they are healthier and that their health care system is better. It’s also something that is relatively easy to measure, compared to other indicators, since even developing countries usually have reasonably good data based on birth and death certificates. And yet, I say “relatively” because there are some conceptual and definitional problems:

  • Exceptional events such as a natural disasters or a war can drag down life expectancy numbers, but those events need not influence health in general or the quality of health care.
  • Wealthy countries may have more deaths from car accidents than poorer countries, simply because they have more cars. This will pull their relative life expectancy down somewhat, given that younger people are more likely to die in car accidents. And if you use life expectancy to measure health you’ll get a smaller health gap compared to poorer countries than is the case in reality (at least if life expectancy is not corrected for this and if it’s not supplemented with other health indicators).
  • How are miscarriages counted? If they are counted as child mortality, they drag down life expectancy rates compared to countries where they are not counted.
  • What about countries that have more homicides? Or suicides? Although the latter should arguably count since suicides are often caused by bad mental health. If a country’s life expectancy rate is pulled down by high suicide rates, life expectancy rates are still a good indicator of health and of the quality of health care, assuming that health care can reduce suicide rates and remove, to some extent, the underlying health causes of suicide. However, homicides are different: a country with a very good health care system, a very high level of health and a high murder rate can have its health rating pulled down artificially when only life expectancy is used to measure health.
  • Differences in diet and other types of risky behavior should also be excluded when comparing health and life expectancy across countries. It’s wellknown, for instance, that obesity is more of a problem in the U.S. than in many countries that are otherwise comparable to it. Obesity drags down life expectancy and reduces the average level of health, so life expectancy rates which are not corrected for obesity rates are still a good measure for health, but they are not a good measure for the quality of the U.S. health care system. If you want to use life expectancy rates to compare the quality of health care systems you’ll have to correct for obesity rates and perhaps for other types of risky behavior such as smoking or the absence of exercise. Maybe the U.S. health care system, even though it “produces” somewhat lower life expectancy rates than in comparable countries, is actually better than in other countries, yet still not good enough to offset the detrimental effects of high average obesity.

Hence, uncorrected life expectancy rates may not be such a good indicator of national health and of the quality of a national health care system. If we return to the case of the U.S., some of this may explain the strange fact that this country spends a lot more on health and yet has somewhat lower life expectancy rates than comparable countries.

Or maybe this discrepancy is caused by a combination of some misuse and waste at the spending side – more spending on health doesn’t necessarily result in better health – and some problems or peculiarities with the measurement of life expectancy. Let’s focus on the latter. As stated above, some cultural elements of American society, such as obesity, pull down life expectancy and worsen health outcomes. But there are other peculiarities that also pull down life expectancy, and that have nothing to do with health. I’m thinking of course of the relatively high levels of violence in the U.S. Death by assault is 5 to 10 times higher in the U.S. than in comparable countries (although those numbers tend to go down with the passing of time). This affects younger people more than older people, and when more young people die, life expectancy rates drop sharper than when more old people die.

However, even if you correct U.S. life expectancy rates for this, the rates don’t move up a lot (see here). The reason is that the numbers of deaths caused by homicide pale in comparison to other causes. Obesity levels, for instance, are a more important cause. But correcting life expectancy rates for obesity levels doesn’t seem appropriate, because we want to measure health. If you leave out all reasons for bad health from life expectancy statistics, your life expectancy rates go up, but your average health doesn’t. Obesity isn’t the same as homicide. Correcting life expectancy statistics for non-health related deaths such as homicide makes them a better indicator of health. Removing deaths from obesity doesn’t. If you have life expectancy rates without obesity, they may be a fairer judgment of the health care system but not a fairer judgment of health: a health care system in a country with a lot of obesity may be equally good as the one in another country and yet result in lower life expectancy. The former country does not necessarily have lower life expectancy because of its underperforming health care system – we assumed it’s of the same quality as elsewhere – but because of its culture of obesity.

However, if you really want to judge health care systems, you could argue that countries plagued by obesity should have a better quality system than other countries. They need a better quality system to fight the consequences of obesity and achieve similar life expectancy rates as other countries that don’t need to spend so much to fight obesity. So, life expectancy is then reinstituted as a good measure of health.

What is Poverty? (5): A Psychological Thing

Poverty is not just the absence of sufficient income or a level of consumption that is below a minimum threshold. Poverty is multidimensional: it also means bad health, high mortality rates, illiteracy etc. And these different elements of poverty tend to have a negative effect on each other (the so-called poverty trap). Being deprived of literacy or education is usually seen as an obstacle to material wellbeing.

The absence of material wellbeing – whether expressed in terms of income, consumption, health, mortality etc. – is often viewed as an isolated evil. However, it’s possible to make the case that it can also have psychological effects that harm people’s mental wellbeing. If this is true, and I think it is, then poverty does more harm than we usually think it does.

I believe it’s widely accepted that poverty does some psychological damage, such as stress, depression, loss of self-esteem and of the feeling of control, loss of ambition and aspirations etc. Although usually people assume – correctly or not – that this type of damage is less severe or less urgent than the physical damage that results from poverty (such as bad health, mortality, hunger etc.). Some even argue that there’s a tendency to overemphasize the link between material deprivation and (the perception of) subjective wellbeing, and that psychological problems which may seem to be caused by material deprivation have in fact other causes (genetics, upbringing, personality etc.).

However, I think the tendency is rather to underestimate the effects on mental wellbeing. A recognition of the psychological effects of poverty would also open the possibility of a more positive evaluation of notions such as poverty as vulnerability and relative poverty. Vulnerability, or a high level of risk of poverty, can perhaps produce the same amount of stress as actual poverty. And one’s self-esteem can suffer as much from actual deprivation (including illiteracy) as from comparative (or relative) deprivation (e.g. comparatively low levels of education or income).