Looking through the World Health Organisation's figures on causes of death the other day (it's a cheerful life, being a development researcher), I was reminded of an astonishing – and shaming – fact. The biggest cause of death in low-income countries is not HIV, TB or malaria, not maternal mortality or any of the things that there are big high-profile funds or campaigns on. In fact, it's the more common-or-garden business of respiratory disease. What the WHO terms "lower respiratory disease" kills nearly 3 million people in low-income countries every year. This is only slightly less than the deaths caused by HIV/Aids, tuberculosis and malaria combined.
For me, this fact poses a big challenge to how we define and act on development problems. It seems astonishing that such a huge cause of death is almost unnoticed by donors, by governments, by NGOs and by development researchers. And all the more so when you consider that the figures imply that the problem is eminently solvable.
In middle- and high-income countries, respiratory disease is down to number four in the death top 10, at around 4% of all deaths. It's clear that something happens to change the grim statistics when countries develop. If we knew what it was, we could probably shortcut the process a little and save millions of lives in the poorest countries. But we're not even asking the question, because we don't even recognise the problem.
Despite the best efforts of a few NGOs, like Practical Action, who have been highlighting this problem for years, and despite the World Health Organisation having done some excellent research on the issue, it's still stubbornly invisible to policy makers, campaigners and funders. Why?
My hunch is that this is yet another example of where gender-blind analysis leads to poor diagnosis and poor outcomes. A huge number – over one-third, according to the WHO – of those deaths are caused by the smoke and fumes from cooking indoors over inefficient stoves or open fires. Smoke is also implicated in pulmonary disease, another leading cause of death. Taking the two together, indoor smoke might be responsible for over a million deaths a year in the poorest countries – more than TB or malaria, and nearly as many as HIV infections. The very young and the old are most at risk, and 60% of those who die are women and girls – who spend more time indoors, where the smoke is.
But cooking is just one of those things that (mainly) women do that is taken for granted and doesn't figure in policy makers', or development professionals' minds as a serious issue for public policy. It doesn't produce anything that can be measured in official statistics, it's not something that changes much year on year, it's not something that anyone ever even notices. It just goes on, day after day, for centuries, killing the very people who are responsible for the most basic acts of keeping other people alive.
Our total ignorance of the main killer in poor countries is perhaps one of the most dramatic examples of where you get development wrong if you ignore gender and other inequalities. A central insight of feminist economics has been how the inequality between the unpaid work done in the "care economy" – the millions of hours spent keeping lives going by cooking, washing, childcare, cleaning and so on – and the productive economy, where work is valued and rewarded financially by the market, is at the heart of much of the economic, social and political inequality between men and women. This schism at the heart of how we see the world is being replicated in our development statistics, our policy making and our practice.
It's hard to see or count work that is invisible in the statistics and data that many of us spend our lives poring over, trusting that it is a fair representation of reality. But because we don't see it, we're getting some things very wrong. Those deaths do matter – for policy makers, as well as for the family and friends of those affected. As aid donors become increasingly preoccupied with value for money, in an era of more and more pressure on aid budgets, getting the question right is crucial. If we're missing the biggest cause of death in the poorest countries, what else are we missing?
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