Infrastructure as a Social Determinant of Health in Developing Economies

By Matthew L Baum

Recently in the New England Journal of Medicine, D.S. Jones described the history of a dangerous new technology, the detrimental health effects of which had clinicians very worried. That technology was the automobile. While the public health concern spanned from inactivity to new maladies like “automobile knee”, by far the greatest concern was automobile accidents. Jones describes that in 1912, accident mortality was such a big problem that a New York coroner’s clerk said “’our streets are becoming as perilous as a battlefield’” and by 1957 the evaluation was not much better:  “Harvard researchers described accident mortality as a ‘mass disease of epidemic proportions’.” Interestingly, Jones highlights that doctors viewed this epidemic not merely as a governmental problem, but one in which there was a moral imperative that doctors themselves play a role in both studying what factors lead to car crashes and (more controversially) identifying high-risk drivers and thus contributing more directly to prevention.

Now in many developing economies across the globe, an interesting twist on this story is emerging: while modern cars have long existed in these locations, only very recently has there been a massive expansion of well-paved roads. And along with new and improved transport routes, new risks to public health.

I recently spent some time in Ethiopia, the anecdotal experience of which I will use to frame the issue. The road from the city of Gonder (rightly famed for its impressive mediaeval castles) towards the Simien Mountains was until recently a dirt road notorious to tourists as particularly bumpy. Over the recent years, Chinese contractors have been building roads all over Ethiopia (see section entitled “Enter the Dragon” in Peter Gill’s recent book, “Famine and Foreigners: Ethiopia since Live Aid”) and sharing road building expertise locally. This road out of Gonder was a recent beneficiary of this phenomenon and is now a paved smooth ride – incidentally much smoother than most of the roads around here in Boston. Land Rangers and minibuses, their pace once hindered by the harshness of the dirt road, can now speed along the dark asphalt. While many view this road building rightly as a good improvement to national infrastructure, it also poses a risk of magnifying a social determinant of ill health.

The sides, and at points the middle, of these roads are jammed with pedestrians on their way to work or school as well as animals being driven to or from market. With the passage of the vehicles no longer kicking up choking dust clouds, the people walk more closely to or more frequently on the road than they used to; because the pedestrians are present only sporadically  along the road, the foot traffic does not uniformly slow to a snail’s pace wheeled traffic (and thus eliminate the benefit of the infrastructure). What does occur is high speed stretches followed by rapid braking or swerving when drivers encounter people or animals on the road. While I was travelling this road, I witnessed an accident where a woman ran out into the road at one of these points and was struck by a minibus that could not stop in time. Certainly this occurrence was terrible for the woman and her family, and for the driver, who according to Ethiopian law would spend his time in jail until the seriousness of the woman’s injuries were clear (the penalty is tied to gravity of the consequences). With faster traffic on roads the risk for this type of occurrence is likely to increase.

Since the White Hall studies and the extensive literature that followed, it is increasingly recognized that low socio-economic status can detrimentally impact health. But in discussions of what type of social determinants contribute to this effect, developments to infrastructure are rarely discussed. Since the pedestrians who are most vulnerable to the increased risk of traffic accidents are themselves poor, it might be reasonable to question whether these infrastructure developments are taking an disproportionate toll on the health of the worst off. If this turns out to be the case, it may be appropriate for local governments (in this case, Ethiopia) to regulate the distribution of development (especially when funded from foreign money) such that the improvement does not unfairly risk health outcomes for the poor (perhaps by earmarking some funding for pedestrian routes in the most congested areas). Clearly, empirical research on the health effects of infrastructure development in these settings would help to guide appropriate response. Whether doctors should view this potential health risk as creating a moral imperative for action within their own community, as they did in the historical development of cars, is also an open possibility.


During his fellowship, Matthew Baum was a second year MD-PhD student in the Health Science and Technology (HST) combined program of Harvard and MIT where he integrated his interests in clinical, scientific, and ethical aspects of mental health. He holds a DPhil at the Oxford Centre for Neuroethics where his doctoral work, supported by a Rhodes Scholarship, concerned the ethical implications of the development of predictive biomarkers of brain disorders. Matthew also completed an MSc in Neuroscience at Trinity College Dublin as a George Mitchell Scholar and holds a BS and an MS in Molecular Biology from Yale. During his medical and neuroscience training he maintained a strong engagement with neuroethics; he has acted as the student representative to the International Society for Neuroethics. During his time at the Petrie-Flom Center, Matt researched the intersection of biological risk and disorder.

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