Using Research to Create Healthy Communities

BY CYNTHIA TOMS, PROFESSOR OF GLOBAL STUDIES AND KINESIOLOGY BASED ON HER TALK AT WESTMONT’S 2019 LEAD WHERE YOU STAND CONFERENCE

I approach development through the lens of global health. It’s personal for me. Twelve years ago, I was living in Uganda when I became pregnant with my first son. About six months into the pregnancy, I woke up with a swollen body, stabbing pains in my abdomen and a searing headache. At the local clinic, I was diagnosed with preeclampsia, the number-one killer of mothers and children worldwide, responsible for eight percent of all maternal and neonatal deaths. My husband was travelling for work, and I had no opportunity to obtain the life-saving medications or blood transfusions I needed. So I reached out for help and started thinking about every resource and network available to me. I called my sister in Maryland, who is a doctor. I called my parents and asked them to get me a plane ticket so I could get to a city and get stabilized. Fortunately, my networks and resources came through, and I got treatment. My son was born weighing just four pounds. We needed those life-saving resources. We both had a long recovery — but we recovered. The medical resources I received, my ability to make choices about what I did with these resources and the connections I made all helped to save our lives. I recovered fully and was blessed to give birth to two more children.

That experience changed me. I was working in health and education when I received the terrifying news about my health. The women helping me, packing my things and getting me to the airport, were people I’d been living with for years. They were women I loved, who cared for me, who belonged to my community and Bible study. For many of them, such a diagnosis may have been a death sentence because they lacked the same tethers to resources that I did. I sat with that for a long time. This defining moment transformed my motivation from good intentions to a resolute commitment to helping others, particularly women, in the field of maternal health.

I began a professional and personal journey to discover what works in development and how I could remain connected to it. Here’s the good news: cutting-edge research — large-scale, randomized trials — provides answers about what works in development. We no longer need to operate with just good intentions or rely on anecdotes and case studies because we can make data-driven decisions. The Poverty Action Lab at MIT and other researchers have been using random assignment to test various interventions: one group receives the resources, and the other doesn’t and becomes the control group. Researchers can then evaluate whether outcomes occurred from the community intervention.

Before we had this data and knowledge, we’d start a program, such as providing all kids with a computer to improve their test scores. But maybe they do better because it rained less and they went to school more often, or maybe their church started a new program about education. There could be lots of reasons. We couldn’t say what would happen if the computer program didn’t exist. With random assignment, we can control all those factors and look at just the intervention. We can do that today because the global community has been researching what works in development for the past 50 years and provides a global scale for our understanding.

According to this research, global health is by far the greatest denominator in reducing poverty. It’s more effective than programs related to education, finance, gender equity or giving away shoes. Significant evidence shows that investing in global health boosts not only personal but national income levels. Even in the United States, the single greatest cause of poverty is often an unexpected medical expenditure. Keeping people from dying is responsible for 11 percent of economic growth in low- and middle income countries in the last 10 years. Getting people healthy and keeping them healthy raises that statistic to 24 percent of economic growth. The evidence is overwhelming: a quarter of all growth in middle- and low-income countries in the last decade came from  improvements to health.

When individuals are healthy, they make up healthy communities. Mothers grow healthy babies. Children have fewer absences at school, so they get better jobs and earn more income. They not only generate more lifetime wealth, but they draw in foreign investment in communities. When income increases, it also helps those who can’t work: elderly, disabled and vulnerable populations.

We’re gaining evidence that our entire economy can benefit when we care for the least healthy in our populations. When people have the freedom to make their own decisions, especially about their health, they reach their greatest capacity, and the entire community flourishes. These findings extend beyond economic and social outcomes. I think of the moral implications of what it means for us to care for the least of these; theologians might call this the preferential option for the poor. One author describes it as “a moral responsibility to care for the most vulnerable and weak so they can also share, take, contribute and give to the common good, so that all may flourish, because the deprivation and the powerlessness of the poor wounds the whole community. The extent of their suffering is a measure of how far we are from being a true community of persons.”

Now we know that supporting global health is the best thing we can do to promote community development. We also know it’s our moral responsibility. So what kind of programs should we promote? We need to provide three things: resources, agency to use those resources and connections to the community.

What’s the fastest way to get resources to a person? The answer to this is simpler than we might think. When our own kids ask us for lunch money, we don’t tell them to get a job, invest their income and buy themselves lunch. No, we give them money to buy lunch because we know they’re hungry, and hungry kids can’t focus in school. Giving people money is one of the fastest ways to get them healthy so they can go on with their daily activities. But we’re fearful that if we give people a resource, they’ll become dependent or entitled. They’ll abuse it. They won’t appreciate it. But giving people money works to a certain extent in these random experiments, which encourages us to think more deeply about the human spirit.

How exactly does getting cash raise us out of poverty and help us to be resilient and hopeful? Here’s an example. Prospera, a program in Mexico, is almost 20 years old. It gives conditional cash transfers to people willing to care for their families. If parents bring their kids in for regular immunizations and doctor’s appointments, they received money wired to their bank  accounts — and if they don’t show up, the program takes their money away. This program has made such a great impact in Mexico, that 52 other countries are now adopting it. The whole development community was wary of this until we started seeing the improvements that resulted.

We see this principle proven in other areas as well. Development economists got together and looked at 30 global health studies involving more than 45,000 people throughout the world. They discovered that charging fees for many preventative health products dramatically reduced their use. But preventative health products distributed for free were used 80 to 94 percent of the time: latrines for sanitation, bed nets, deworming medicine, vitamins and other global health interventions. Global health works in development, and access to cash helps lift the burden of poverty and allows people to make better choices.

But we don’t see this in the numbers, we see it in human ways. In global development, hope is a key indicator of what works. Having agency — the ability to act for yourself on your own behalf — is an important factor because it builds hope. A team of development economists conducted a random control study among 320 villages and more than 6,000 low- income families in the Philippines. It proved scientifically through data that value-based programs — in this case Christian values — help people better adhere to intervention programs. Group A heard lectures on both values and health and received livelihood training based in a church. Group B got health and livelihood lectures in a government center. Group C heard just the values lecture, and group D was a control group with no intervention. The values- based education, along with information about health and livelihood, increased income by 10 percent over any other group. Combining talk about the human spirit and helping people work through their motivations with training about facts made a significant difference. The research attributed the growth to value- based training that gave people hope they could change their circumstances.

Living in poverty can give many people a sense of fatalism and make them think their circumstances are set by someone else and will never change. If we empower people to believe that they have agency and choices and give them opportunities to believe this, it makes a difference. Another team of researchers examined the role of aspirational hope in microfinance borrowers and child-sponsorship programs and found that attitudinal hope makes a statistical difference in development programs in emerging income countries.

Let me repeat that: Hope makes a statistical difference in community development. One author titled his article “The Secret Ingredient of Poverty Relief,” which says, “Aspirational hope has one crucial element: those who have a belief that they can make a difference.” People who use resources must believe they can accomplish their goal. They must not only have agency to make choices but also believe in their agency. I’ve seen this in my own research in Costa Rica, where I found that homestay mothers felt the greatest impact of economic development when volunteers visited their communities. These women had no opportunity to work outside of their home, so all their money came from their husbands, who often dictated what they could do with it. But when volunteers paid to stay in their home, the money went directly into the homestay mother’s pocket. The large majority of women used this money for better diets for their kids, school fees and clothes so their kids would feel better when they went to school. But it also contributed to happiness. I remember listening to a young woman who smiled broadly and said, “I did all that, but I had some money left, so I bought these fancy pants, which I love and wear almost every day!”

I’ve also been part of a team in Santa Barbara supported by a USDA grant that addresses food security in our neighborhood. We’re examining food choices by young adults. According to the initial data, when people can choose what they eat, they tend to make healthier choices and feed their families with a diet more laden in vegetables.

Why should this connectedness be important to us? People are happier when they’re able to give. In many ways, generosity makes us happy. In fact, according to a recent article in the journal Nature, generosity is becoming a predictor of happiness. Researchers have discovered a neural link between generosity and happiness. But there’s a catch: It matters how we do it. We find joy in helping others when we can envision where our dollars are going and when we feel a connection to the people we’re helping. Authentic connection with the people and the cause we’re supporting may predict sustainable giving and self-fulfillment.

I want to talk a bit about reciprocity: the idea of connectedness through sustained reciprocity. We know networks are stronger when we receive as well as give. We build social capital by both giving and receiving from that same network. I learned this when I had to ask for help and rely on people in the community to save me and my son. It’s the idea of give and take. When people return from a trip of service, they often say, “I went to serve, but I got more than I gave.” Something in that giving and receiving works in our brains. Henry Nouwen, one of my favorite authors, calls this “voluntary displacement — an opportunity to voluntarily change our common and often comfortable circumstances and come into solidarity with those who are vulnerable. The discipline reminds us all of our own vulnerability and our own dependence on others and helps us to remain in touch with our greatest gifts of gratitude and compassion.”

We know that health is the single greatest factor in decreasing poverty and promoting development in low- and middle-income families. We know that randomized experiments get resources to people and that giving them agency and choices will foster hope that their circumstances will change. And we’ve learned we can be a part of this whole process by getting involved personally in a cause and finding something we care about. For me, maternal health will always be inextricably linked to my life. When we find that cause, that place that intersects with our life, and give generously, we are more likely to find better happiness and health for ourselves and to help others obtain human flourishing. Global health can lead to human flourishing for us all. We are all better together.