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Abstract Austin, Kelly Fawcett. A ABSTRACT AUSTIN, KELLY FAWCETT. A New Infection and the Forgotten Diseases: HIV, Tuberculosis, and Malaria in Less-Developed Nations. (Under the direction of Edward L. Kick, Ph.D.) HIV, tuberculosis, and malaria represent a triple threat to development and well-being in less- developed nations. Despite amazing variation in HIV, TB, and malaria rates across nations, there are few cross-national assessments of the determinants of these diseases. Utilizing insights from neoliberal modernization and world-systems/dependency perspectives, the analyses examine how infrastructural, social, economic, and environmental factors influence HIV, TB, and malaria prevalence in less-developed nations. The results demonstrate the importance of TB and malaria alongside HIV in contributing to heightened cross-national life expectancy inequality, and also illuminate important indirect relationships among environmental decline, urban growth, GDP per capita, health infrastructure, and disease. In addition, environmental degradation associated with export agriculture is found to be a major factor contributing to elevated rates of malaria prevalence. Overall, the results bring attention back to the forgotten diseases of TB and malaria, and demonstrate important ways that development and dependency conditions combine to influence disease outcomes in poor nations, thereby reproducing conditions of global inequality. © Copyright 2012 by Kelly Fawcett Austin All Rights Reserved A New Infection and the Forgotten Diseases: HIV, Tuberculosis, and Malaria in Less-Developed Nations by Kelly Fawcett Austin A dissertation submitted to the Graduate Faculty of North Carolina State University in partial fulfillment of the requirements for the degree of Doctor of Philosophy Sociology Raleigh, North Carolina 2012 APPROVED BY: _______________________________ ______________________________ Edward L. Kick Brett Clark Committee Chair ________________________________ _______________________________ Sarah Bowen Theodore N. Greenstein ii DEDICATION This dissertation is dedicated to my sister Holly, my uncle Brendon, and all others who have left this world too quickly and now live with us in our hearts. iii BIOGRAPHY Kelly Fawcett Austin was born and raised in the Santa Cruz Mountains of central California. There she enjoyed a childhood filled with hiking, camping, horseback riding, and exploring in the redwoods and large oaks with her parents and beloved dog, Roxy. During her teenage years Kelly and her parents moved to Ashland, Oregon, where she graduated from high school in 2001. Kelly attended college at Oregon State University, in Corvallis, Oregon. There she met her husband, John Austin, who shares her love for family and the outdoors. In June of 2006 Kelly graduated from OSU with a B.S. in Human Development and Family Sciences and a B.A. in Sociology. In 2007, Kelly and John moved to Raleigh, North Carolina. Kelly earned a Master’s degree in Sociology from North Carolina State University in 2008 and continued her research on global inequalities while pursuing a Doctorate degree. Starting in the fall of 2012, Kelly will be an assistant professor of sociology at Lehigh University in Bethlehem, Pennsylvania. iv ACKNOWLEDGMENTS I would like to express deep thanks and appreciation to Dr. Ed Kick and Dr. Brett Clark. Both have been amazing in providing constant support, guidance, and patience. Throughout my graduate school experience, Ed and Brett have always been there, willing and happy to advise me on countless occasions. I know that having such dedicated mentors has greatly contributed to my growth and development as a sociologist and as a person. I am also deeply indebted to Dr. Sarah Bowen, Dr. Ted Greenstein, and the other faculty in the sociology and anthropology department for their insightful and helpful contributions on earlier drafts of this dissertation, as well as regular assistance and support on other projects throughout my tenure at North Carolina State University. I also want to acknowledge my family and friends, whose help and encouragement has been crucial in contributing to the success of this project and the pursuit of my doctoral degree more generally. Thank you to my parents, Brad and Cris, for encouraging me to study hard, be independent, and never lose sight of my goals. I also thank my husband John, who moved across the country so that I could achieve all of my aspirations, and who is always there when I need him to pick me up and keep pushing me forward. I am also deeply indebted to my colleagues and friends, including Kelly Thames, Laura McKinney, Gretchen Thompson, and other peers who could always be counted on for a good laugh and helpful advice when I needed it. v TABLE OF CONTENTS List of Tables.................................................... viii List of Figures.................................................... ix Chapter 1: Disease and Development.................................... 1 Prologue.................................................. 1 HIV, TB, and Malaria: A Triple Threat in Less-Developed Nations............ 5 Neoliberal Modernization and World-Systems/Dependency Perspectives on Development.............................................. 7 Cross-National Evidence on Development and Physical Well-Being............. 13 Emerging Questions about HIV, TB, Malaria, and Well-Being in Less-Developed Nations................................................... 23 Chapter 2: Cross-National Life Expectancies and HIV: The Forgotten Role of Malaria and Tuberculosis................................................... 25 Introduction.............................................. 25 Development, Life Expectancy and Disease: Theories and Research........... 27 Tuberculosis, Malaria, and HIV: A Triple Threat to Life Expectancy Rates...... 32 Hypotheses................................................ 37 Methods.................................................. 38 Results................................................... 45 Conclusion................................................. 52 vi Chapter 3: HIV, Urbanization, and Differing Impacts of Female Empowerment in Sub-Saharan Africa........................................................ 64 Introduction.............................................. 64 Characteristics of HIV in Less-Developed Nations....................... 67 Hypotheses................................................ 75 Methods.................................................. 77 Results................................................... 81 Conclusion............................................... 86 Chapter 4: Environmental Change, Urban Slums, and the Forgotten Plagues: Tuberculosis and Malaria....................................................... 95 Introduction............................................... 95 The Forgotten Plagues and Patterns of Underdevelopment.................. 98 Hypotheses................................................ 106 Methods.................................................. 107 Results................................................... 113 Conclusion................................................. 115 Chapter 5: Export Agriculture is Feeding Malaria Rates in Poor Nations............. 122 Introduction.............................................. 122 Malaria Resurgence and Environmental Degradation..................... 124 Development, Environmental Degradation, and Human Well-Being........... 129 Hypotheses................................................ 133 vii Methods................................................. 134 Results.................................................. 139 Conclusion................................................ 142 Chapter 6: Theory, Policy, and Practice: Plaguing Prospects for Infectious Disease in Less- Developed Nations.............................................. 149 General Conclusions........................................ 149 The Perils and Pitfalls of Neoliberal Development Strategies............... 152 International Health Programs and the Limitations of Ad Hoc Practices....... 158 Limitations and Future Research................................. 163 Conclusion.............................................. 165 viii LIST OF TABLES Table 2.1: Nations Included in the Life Expectancy Analyses...................... 57 Table 2.2: Correlation Matrix and Univariate Statistics for Life Expectancy Analyses...... 58 Table 2.3: Random Effects Regression of HIV Prevalence on Life Expectancy......... 59 Table 2.4: Random Effects Regression of TB Prevalence on Life Expectancy.......... 60 Table 2.5: Random Effects Regression of Malaria Prevalence on Life Expectancy........ 61 Table 2.6: Random Effects Regression of Disease on Life Expectancy over Time - Including Regional Interaction Terms........................................... 62 Table 2.7: Random Effects Regression of Disease on Life Expectancy over Time - Allowing for Comparisons in the Effects of Disease................................... 63 Table 3.1: Nations Included in the HIV Analyses............................. 91 Table 3.2: Univariate Statistics and Correlation Matrix for HIV Prevalence............ 92 Table 4.1: Nations Included in the TB/Malaria Analyses........................ 119 Table 4.2: Univariate Statistics and Correlation Matrix for TB/Malaria Prevalence........ 120 Table 5.1: Nations Included in the Malaria Analyses........................... 146 Table 5.2: Correlation Matrix and Univariate Statistics for Malaria Prevalence........... 147 ix LIST OF FIGURES Figure 3.1: SEM Predicting HIV
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