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MORTALITY IN LESS DEVELOPED COUNTRIES 229

and international bodies have found relevant Economic inequality
in order to bring about reductions in mortal-
ity in less developed countries. Some researchers question the utility of eco-
nomic development in explaining health and
mortality without taking economic inequality
into account (Anand and Ravallion, 1993;
Economic development
Flegg, 1982; Houweling et al., 2005; Rodgers,
Income is known to be a robust and strong 2002; Sen, 1998; Wilkinson, 1996), although
determinant of mortality. Following the classic there is a body of literature that is sceptical of
study of Preston (1975, 1976), a number of the inequality–mortality hypothesis (for a
studies examined the relationship between review, see Lynch et al., 2004). Considerable
income and mortality at the national level evidence has accumulated to show that
and found that mortality fell rapidly during despite impressive economic growth in many
the early stages of economic development countries over the past 50 years or so, large
and then levelled-off at later stages (Deaton, masses of their population have remained in
2003). It appears that a small rise in per poverty. Economic growth has not benefited
capita income results in large reductions in a vast segment of their populations. It is
mortality, especially during the early stages argued that the effect of economic develop-
of epidemiologic transition. Once mortality ment on mortality depends on how its bene-
has reached a relatively low level (e.g., with fits are distributed between various segments
a life expectancy around 70 and an infant of a population and the mechanisms through
mortality rate around 20), income does not which it operates to reach the poor and disad-
seem to make much difference. vantaged who are most vulnerable to high
We also find that there are wide variations morbidity and mortality. Inequality tends to
in mortality, suggesting that mortality reduc- reduce access to health services and medical
tions can occur without significant economic facilities even when they are available.
development (World Bank, 2003). An exam- Studies have shown time and again that a
ination of the correlation between annual somewhat similar socioeconomic gradient in
growth rate in the gross domestic product disease and mortality, with lower rates
and the annual change in the infant mortality among the rich and higher among the poor,
rate reveals that there is a weak relationship exists in every country, developed or
between changes in per capita income and less developed. The gradient remains largely
changes in infant mortality. The most impres- unaltered even when socioeconomic differ-
sive declines in infant mortality occurred in ences in medical care or life style factors,
countries with improved economic situation, such as smoking, unhealthy eating, or risk-
albeit only slightly. However, mortality taking behaviours are accounted for
declined even in countries which have not (Marmot, 2001). The essence of this argu-
experienced much improvement in their eco- ment is that the problems associated with ill
nomic conditions or have experienced a health that affect the poor, less educated, and
decline, whereas it declined with varying underprivileged disproportionately are not
rates for countries with similar rates of necessarily a consequence of their different
economic growth. As Preston (1975, 1976) life style. Rather, their disadvantaged social
argued, factors exogenous to a country’s cur- status, deprived neighbourhoods, and work
rent level of income, such as the import of environment translate directly or indirectly
health and medical technologies, anti-malarial into poorer health in several major
programme, and mass immunization may ways. Data collected by the Demographic
have played a far greater role than economic and Health Surveys on infant mortality rates
development per se in explaining mortality by asset quintile for various less devel-
declines in many less developed countries. oped countries, around 2000 are revealing