Does economic inequality affect child malnutrition? The case of Ecuador

Abstract

Economic inequality has been hypothesized to be a determinant of population health, independent of poverty and household income. We examined the association between economic inequality and child malnutrition in Ecuador. Economic inequality was measured by the Gini coefficient of household per capita consumption, estimated from the 1990 Census. Childhood stunting, assessed from height-for-age z scores, was obtained from the 1998 Living Standards Measurement Survey (LSMS). We controlled for a range of individual and household covariates, including per capita food consumption, education, housing, ethnicity, fertility, access to health services, diarrhea morbidity, child care, mother's age and diet composition. Stunting still affects 26% of children under five in Ecuador, with higher prevalence in the rural Highlands and among indigenous peoples. Maternal education, basic housing conditions, access to health services, ethnicity, fertility, maternal age and diet composition were independently associated with stunting. However, after controlling for relevant covariates, economic inequality at the provincial scale had a statistically significant deleterious effect on stunting. At municipal or local levels, inequality was not associated with stunting.

Introduction

Recent research has suggested an association between income inequality and health in the United States, after controlling for individual SES and other confounding variables (Lochner, Pamuk, Makuc, Kennedy, & Kawachi, 2001; Kennedy, Kawachi, Glass, & Prothrow-Stith, 1998; Blakely, Lochner, & Kawachi, 2002; Kahn, Wise, Kennedy, & Kawachi, 2000; Diez-Roux, Link, & Northridge, 2000; Subramanian, Kawachi, & Kennedy, 1999). However, studies in countries outside the USA, based mostly on empirical evidence from Western Europe and Japan, failed to identify a statistically significant association between income inequality and population health (Mackenbach, 2002).

The bulk of research however, remains based in wealthy societies, most of which are more egalitarian in their distribution of income compared to the United States. It has been speculated that the lack of association between income inequality and health in wealthy countries (besides the USA) reflects a threshold effect of income distribution (Subramanian and Kawachi, 2004). Latin America is widely acknowledged as one of the most inegalitarian regions in the word (IADB, 2000), so that the region provides an ideal setting for testing the hypothesis that income inequality is deleterious to health (Subramanian, Delgado, Jadue, Vega, & Kawachi, 2003).

The aim of this paper is 2-fold. Firstly, we provide an empirical and analytical contribution to the ongoing debate on the effects of economic inequality on health, through a country case study in a Latin American country; and secondly, we examine the social, ethnic and demographic determinants of child malnutrition in Ecuador. This article probes the effect of economic inequality on chronic child malnutrition (stunting) in Ecuador, controlling for a range of household and individual determinants.

Ecuador, one of the small and less developed countries in the Latin American region, has been historically characterized by high social and ethnic disparities. Ecuador has been undergoing the epidemiological transition, and has experienced severe shortcomings in access to basic health services. In a society characterized by pervasive poverty and basic need deprivations, individual health achievements depend not only on household socio-economic circumstances, but also on social investment in health (and its positive externalities). Economic inequality reduces social cohesion, weakens local institutions, governance and accountability, and increases social conflict. (Kawachi & Berkman, 2000). In turn, these effects are hypothesized to affect the level and efficiency of health investment.

Child malnutrition is still widespread in Ecuador, with a national prevalence of 26% in 1998, and the highest rates recorded among indigenous groups (58%) and the rural highlands (41%). Moreover, the declining trend in malnutrition observed since 1986 has been modest, and was accompanied by increasing disparities (Larrea, Freire, & Lutter, 2001).

Ecuador clearly belongs to the group of less developed countries in Latin America, with a per capita income of US$1461 in 2001, substantially below the regional average of US$3864. The country ranked in position 97th among 175 countries in the world, according to the UNDP Human Development Index in 2003, with the second-worst position in South America, only above Bolivia (UNDP, 2003). Social, regional and ethnic disparities, which have historically affected the country, remain pervasive.

After a process of significant economic growth and social improvement stimulated by banana exports in the 1950s and oil exports in the 1970s, Ecuador's economic performance has been affected by a long-lasting stagnation and a deep economic crisis from 1998 onwards. In fact, current per capita income is still slightly below the figure for 1980. In 1998, 63% of the population had a household consumption below the poverty line, and poverty reached 82% in the countryside and 87% among indigenous groups. Adult illiteracy remains at 10% at the national level, and 18% in the countryside, while infant mortality remains at 30 per thousand live births. The Gini coefficient of urban income distribution in Ecuador (0.57) is the third largest among 14 Latin American countries, below only Paraguay and Brazil (Larrea & Sánchez, 2002; UNDP, 2001; CEPAL, 2001; IADB, 2000).

In spite of significant economic and social progress, Ecuadorian society remains deeply fragmented along regional, social and ethnic lines. The Andean mountains cross the country from North to South, differentiating three regions: the tropical Coast, the Highlands, and the Amazon basin. A significant expansion of indigenous cultures took place in the Highlands before the Spaniard conquest. Colonial society, consolidated in this region during the sixteenth and seventeenth centuries, was based on a concentrated pattern of land ownership and exclusionary social institutions whose heritage still prevails. At the bottom of the Highlands social scale remain the indigenous populations, who provided coerced labor to the traditional white elite from the 16th century to the 1960s, and continue to have reduced access to land, water, education and social services. By contrast, the two lowland regions, the Coast and the Amazon basin, became mostly integrated into the national economy during the republican period (1830 to the present), and have lower levels of social inequality (Fig. 1 and Table 2). While economic inequality and stunting affect mostly the Highlands, particularly the provinces with high indigenous populations, the regional distribution of aggregate consumption and income follows a more complex pattern, favoring the two metropolitan provinces, and also affecting rural areas in all regions (Fig. 1).

Child malnutrition, a major hindrance to human development, jeopardizes and impairs prospects for productive social integration in adulthood, reduces economic growth, and contributes to the intergenerational reproduction of poverty and inequality. Although the immediate causes of malnutrition are inadequate nutrient intake and high disease exposure, underlying factors include social and ethnic disparities, as well as lack of access to basic health services.