# Lentis/Social Obstacles to Public Health in Developing Countries

Public health covers a broad range of meaning. It can refer to the medical processes or to practices that promote healthy lifestyle. Public health agencies in the developing countries face many social obstacles, a lot of which are not faced in developed countries. The major obstacles are financial constraint, lack of the knowledge, religions, and social norms. In this Lentis chapter, we will be exploring these obstacles using 3 specific case studies. These obstacles can be characterized using knowledge, attitude, behavior (KAB) approach, which can also be applied to a wide range of social obstacles e.g. in climate change, nutrition, and education.
* K= Knowledge: Misunderstanding due to lack of knowledge.
* A= Attitude: Different perception: belief in supernatural power instead of Western medicine.
* B = Behavior: Social shunning for using condom and helmet.

## List of obstacles
### Poverty

The medical expense in developing countries is cheaper than in developed countries because of governmental subsidies. Despite this, medical expense constitutes a higher percentage of the income of people in developing countries. Yet, higher expenditure does not indicate higher quality of health care. Cohen et al. found that the demand of the deworming medication in Kenya was close to 20% when the drug was $US0.30 and increased to 80% when it is free.. Similarly, Ashraf et al. found that a water-treatment product in Zambia increased from 50% to 80% when the price decreased from US$0.25 to $0.10. Most households reported financial limitation as the main reason for not acquiring health care. In attempt to keep their medical expenses at the minimal, the citizens of developing countries are inclined to assume that their sickness can be self-treated and thus not seek treatment until their symptoms become critical. Because the treatment fee associated with the critical stage treatment is generally higher than that of the early stage, they are spending more than they should.

### Lack of knowledge

When faces with unknown phenomenon, rather than seeking scientific explanations, citizens in developing countries sometimes solve them based on their experience and beliefs. While the successful guesses and solutions become the folk wisdom passed on to the next generation, the unsuccessful may induce damage to the individual or the community. A lot of people did not have a chance to learn how vaccines, antibiotics, and Western medicine work.

### Religion

A lot of people, more so in developing countries, believe in supernatural powers and religions other than Christianity. Some of these people are prohibited by their religions to rely on drugs and surgical procedures. Instead of relying on Western medicine, they would use their own folk remedies to cure illnesses. For example, Hindus believe that yogis have healing powers and would seek them in place of doctors.

### Social Norms

Norm usually emerges from previous beliefs or standard of the society. It usually is a result of the expectation of good behavior from social perspective. In this kind of social norm, when broken, the consequence does not invite legal punishments, but it may induce social shunning or ostracism. In developing countries, standing out from the crowd violates this kind of social norm. This very notion is an obstacle to public health in many developing countries.

## Puppy Pregnancy Syndrome

A large population in India suffers from puppy pregnancy syndrome. They believe that dog bite may lead to the birth of puppies inside human body. People who are suffering from this syndrome think that the puppies cause severe abdominal pain, fatigue, and inevitable death if left untreated. They believe that solution to saving their life lies not in scientific knowledge and modern public health, but rather Bara Ojhas, “medical” specialist, to cure them. Bara Ojhas will mix herbs with yogurt and flatten rice and feed them to the patient. With some rituals, the medicine dissolves the puppies and their carcasses will pass through urine and stool without the knowledge of the patient.
Puppy pregnancy syndrome demonstrates many social obstacles that prevent Indian from receiving the proper healthcare. Most importantly, the patient lack of the knowledge to verify their beliefs. 79% of adult villagers are certain about the existence of puppy pregnancy syndrome, while 9% do not believe in the syndrome. Getting bitten by dogs can lead to infection and perhaps death if left untreated. Without knowing that Pasteurella spp infection caused by dog bites may lead to death, patients conclude that the bites will result in the birth of puppies in their body. Without the knowledge, patients are easily persuaded by Bara Ojhas in believing that puppy pregnancy syndrome is real and can only be cured by them.

## Religious Oppositions to Public Health Policy on Euthanasia in China

According to research at Xi'An Medical University, “euthanasia in China is gaining increasing acceptance among physicians, intellectuals, and even the people”. Although euthanasia is currently illegal in China, Chinese families and doctors have been practicing passive and even in some cases active euthanasia. On a scale of 1 to 5 with 1 indicating strongly agree, the mean scores of general household and doctors in Hong Kong on general euthanasia are 2.665 and 2.524 respectively.

#### A Case study: Euthanasia as a public health policy

Euthanasia as a public health policy is still debatable as there are great arguments on both sides of the debate. According to a survey of Chinese doctors on primary reasons for opposing euthanasia, 71% selected legal reasons, 18% religion, 49% tradition, and 29% family. Instead of a full picture of the debate, the Chinese religious oppositions that are often tied to tradition and family values will be focused here.

##### Chinese Buddhism

Buddhism constitutes around 17% of Chinese population. Although there are many different Buddhist sects in China, nearly all opposes involuntary euthanasia in principle. Chinese Mahayana Buddhism believes that a person is suffering due to sins in the current/previous lives. If a person kills himself to avoid suffering, in his reincarnation, he will have to pay the same karma in addition to the karma of suicide. Still, Chinese Buddhists has a more favorable towards euthanasia than Chinese Protestants. This may be due in part to Buddhist principle of compassion, the desire to relieve others of suffering. However, one of the common Buddhist precepts is abstaining from killing, so performing euthanasia may disrupt Buddhist practice and incur additional negative karma from breaking the precepts.

##### Confucianism

In comparison, Confucianism, widely practiced in Chinese history, is more tolerate towards euthanasia. Confucianism is more humanistic and non-theistic, focusing on social harmony and ethics instead of after-life or beliefs in the supernatural. Hence, many Chinese people still have the mental models derived from Confucianism and practice them along with Taoism and/or Buddhism. One of the core themes in Confucian thought is Ren (仁), Ren, meaning benevolence. According to the Confucius Analects,
Confucius believes that it is acceptable to sacrifice one’s life to uphold this ren. A famous case is Wen Tianxiang, a scholar-general who committed suicide during the Mongol conquest of China. He wrote a short poem which goes
Confucianism endorses the five relationships and believes that these relationships should be governed by li, propriety. One of li teachings promotes filial piety. If the parents of an individual oppose euthanasia, it would be considered very unfilial for that individual to request euthanasia. In Confucius’s The Classic of Filial Piety, there is a line that goes:
In the decision-making process of euthanasia, Hong Kong residents and doctors listed family member/relative as a close second decision maker following the person him/herself.

##### Taoism

Taoism, which comprises of 0.4% of Chinese population is less tolerant of the idea of euthanasia. The importance is the distinction of "letting die" and "causing death". Taoism emphasizes on wuwei meaning "do nothing”: attempts to prolong or shorten life are unnatural. Consequently, Taoism supports passive but not active euthanasia.

#### Takeaway point

The attitudes, derived in part from tradition and religious practices, have a significant impact on euthanasia practices that is prohibited by law but is gaining popularity. Therefore, it is important to consider these attitudes when crafting public health policies.

## Condom Use in Thailand
#### Introduction

One of the ongoing problems in Thailand is the growing of HIV infection and unplanned teenage pregnancy rates, even when condoms are available in almost all of the convenient stores and local medical centers. In Thailand, discussing about sex is a taboo. It is this reason that Thai people do not feel comfortable enough to buy condoms. They are afraid of receiving social rejection.

#### Statistical data

Thailand's Ministry of Public Health reported that the country has the highest teenage pregnancy rate in Southeast Asia. Thailand has a relatively high adolescent fertility rate at 44 per 1000 women ages 15-19. The rate is higher than in the United States and six times higher than Malaysia’s teenage pregnancy rate.. The Ministry of Public Health reported that the number of HIV/AID patients in Thailand reached over 1 million in 2012, 84 percent of which were the result from unprotected sex.

#### A Case Study

Thailand’s Department of Disease Control and the Ministry of Public Health released an advertising campaign under the Global Fund’s support. The purpose of the campaign was to educate people that buying a condom or asking for one was not a taboo and such action was encouraged. However, the Non Government Organizations (NGO) demanded that the campaign be taken out because the content was rather ambiguous for teenagers. They claimed that promoting condom use can be interpreted as promoting a sexual practice among teenagers. They suggested that the advertising campaign explicitly indicated the target audiences.   Mechai Viravaidya, an AID/HIV activist, founded The Population and Community Development Association (PDA) in 1974. He aimed that the association would complement the efforts of the Thai Ministry of Public Health and the Department of Disease Control in promoting family planning and HIV awareness. One of the many steps to promote HIV awareness was to team up with the traffic police in a campaign called “Cops and Rubbers,” where traffic polices gave out condoms in the middle of traffic in Bangkok. In 2005, the association reported that the annual population growth rate in Thailand decreased to 0.6% (of total population) from 3.3% in the mid-1970s.. Mechai Viravaidya later earned the sobriquet of “Mr.Condom” in 2007.   In 2003, The Ministry of Public Health targeted schools and universities hoping to decrease HIV/AID and unplanned teenage pregnancy rates among students. One of many practices was to have schools and universities mandatory installed coin-operated condom vending machines on campus. However, Thai student leaders expressed opposition to this practice. They feared that such practice would encourage sexual activities among students.. The Ministry later abandoned this plan. Dr. Sombat Thanprasertsuk, the director of the Bureau for AIDS, Tuberculosis and Sexually-Transmitted Infections said that
             "We may propose this again when society feels ready."
Nevertheless, condom vending machines are available throughout the government facilities, supermarkets, and malls. In 2013, Tesco Lotus introduced the country’s first self-service checkout.. The latent function of self-service checkout acts similarly to the manifest function of condom vending machine which helps to decrease social pressure when buying a condom in public.

#### Takeaway point

The perspective of people in the society determines whether promoting HIV awareness and condom use campaigns will be successful or not. Therefore, one of the challenges to public health in Thailand lies within the norms of the society.

## Future Extension

Curing Malaria in Africa (Gates Foundation)

## References

* ↑ How we Classify Countries. (n.d.). Data. Retrieved December 8, 2013, from http://data.worldbank.org/about/country-classifications
* ↑ Cohen, Jessica, and Pascaline Dupas(2010) "Free Distribution or Cost-Sharing?Evidence from a Randomized Malaria Prevention Experiment" Quarterly Journal of Economics
* ↑ Ashraf, Nava, James Berry and Jesse Shapiro.(2010)."Can Higher Prices Stimulate Product Use? Evidence from a Field Experiment in Zambia" American Economic Review.1
* ↑ Guyatt, Helen L., Sam A. Ochola and Robert W. Snow. (2002)."Too Poor to Pay:Charging for Insecticide-Treated Bednets in Highland Kenya." Tropical Medicine and International Health
* ↑ Midnapur, W., & Rahman, S. (n.d.). Medicine challenges Indian superstition. DW.DE. Retrieved December 11, 2013, from http://www.dw.de/medicine-challenges-indian-superstition/a-16489334
* ↑ Bering, J. (n.d.). Puppy Pregnancy Syndrome: Men Who Think They Are Pregnant with Dogs. Scientific American. Retrieved November 29, 2013, from http://blogs.scientificamerican.com/bering-in-mind/2011/11/15/puppy-pregnancy-syndrome-men-who-are-pregnant-with-dogs
* 1 2 Pu, S. D. (1991). Euthanasia in China: A Report The Journal of Medicine and Philosophy. http://jmp.oxfordjournals.org/content/16/2/131
* 1 2 Public Attitudes toward Euthanasia in Hong Kong (2001). http://fhbgrants.netsoft.net/report/631002fr.pdf
* ↑ Department of Health in New York (2011). Crafting Public Policy on Assisted Suicide and Euthanasia. http://www.health.ny.gov/regulations/task_force/reports_publications/when_death_is_sought/chap6.htm
* ↑ Keown, J. (2002). Euthanasia, Ethics and Public Policy An Argument Against Legalisation. Cambridge: Cambridge University Press.
* ↑ 李晓雅 (2010). "“我国实行安乐死是否可行”医师调查显示：近70%的中国医师不反对安乐死. MdWeekly. http://mdweekly.cn/doc/2010/07/26582.shtml
* 1 2 Association of Religion Data Archives (n.d.). Retrieved on 12/11/2013 from http://www.thearda.com/internationalData/countries/Country_52_1.asp
* ↑ Pew Research (2012). "Buddhist." http://www.pewforum.org/2012/12/18/global-religious-landscape-buddhist/
* 1 2 3 Ping-cheung, L. (2010). Euthanasia and Assisted Suicide from Confucian Moral Perspectives. http://link.springer.com/article/10.1007%2Fs11712-009-9147-4
* ↑ http://fhbgrants.netsoft.net/report/631002fr.pdf
* ↑ The World Bank,(2013).Adolescent fertility rate (births per 1,000 women ages 15-19).(2013).Retrieved from http://data.worldbank.org/indicator/SP.ADO.TFRT
* ↑ NNT,(2012, March).Over 1 million Thais are infected with HIV/AIDs. Retrieved from http://www.pattayadailynews.com/en/2012/03/19/over-1-million-thais-are-infected-with-hivaids/
* ↑ INN news, (2007). Backlash on condom advertising campaign(translated). Retrieved from http://hilight.kapook.com/view/15430
* ↑ TED Talk, How Mr. Condom Man made Thailand a better place, Mechai Viravaidya http://www.ted.com/talks/mechai_viravaidya_how_mr_condom_made_thailand_a_better_place.html
* ↑ The Population & Community Development Association. http://www.pda.or.th/
* ↑ Public health minister suggested that all universities install condom vending machines http://www.thaivisa.com/forum/topic/58281-condom-vending-machines-to-be-installed-in-universities/
* ↑ Thai student leaders against condom-vending machine on campus. http://www.chinadaily.com.cn/en/doc/2003-11/28/content_285753.htm
* ↑ Thai Government Drops Plan for Condom Machines at Universities. http://www.thebody.com/content/art29290.html
* ↑ Pay it for yourself avoid waiting in lines, (2013). Retrieved from http://www.bangkokpost.com/learning/learning-from-news/342644/pay-for-it-yourself-avoid-waiting-in-lines