The Political Economy of Climate Adaptation and Environmental Health: The Case of Ethiopia

The environment affects our health, livelihoods, and the social and political institutions within which we interact. Indeed, nearly a quarter of the global disease burden is attributed to environmental factors, and many of these factors are exacerbated by global climate change. Thus, the central research question of this dissertation is: How do people cope with and adapt to uncertainty, complexity, and change of environmental and health conditions? Specifically, I ask how institutional factors, risk aversion, and behaviors affect environmental health outcomes. I further assess the role of social capital in climate adaptation, and specifically compare individual and collective adaptation. I then analyze how policy develops accounting for both adaptation to the effects of climate and mitigation of climate-changing emissions. In order to empirically test the relationships between these variables at multiple levels, I combine multiple methods, including semi-structured interviews, surveys, and field experiments, along with health and water quality data. This dissertation uses the case of Ethiopia, Africa’s second-most populous nation, which has a large rural population and is considered very vulnerable to climate change. My fieldwork included interviews and institutional data collection at the national level, and a three-year study (2012-2014) of approximately 400 households in 20 villages in the Ethiopian Rift Valley. I evaluate the theoretical relationships between households, communities, and government in the process of adaptation to environmental stresses. Through my analyses, I demonstrate that water source choice varies by individual risk aversion and institutional context, which ultimately has implications for environmental health outcomes. I show that qualitative measures of trust predict cooperation in adaptation, consistent with social capital theory, but that measures of trust are negatively related with private adaptation by the individual. Finally, I describe how Ethiopia had some unique characteristics, significantly reinforced by international actors, that led to the development of an extensive climate policy, and yet with some challenges remaining for implementation. These results suggest a potential for adaptation through the interactions among individuals, communities, and government in the search for transformative processes when confronting environmental threats and climate change.

Pitit se rìches malere [Children are the wealth of the poor]: The Influence of Gender and Power on Choice and Uptake of Long Acting Contraceptives

Background: Haiti has the highest maternal mortality rate in the Latin American and Caribbean region. Despite the fact that Haiti has received twice as much family planning assistance as any other country in the western hemisphere, the unmet need for contraception remains particularly high. Our hypothesis is that unsuccessful efforts of family planning programs may be related to a misconstrued understanding of the complex role of gender in relationships and community in Haiti. This manuscript is one of four parts of a study that intends to examine some of these issues with a particular focus on the influence of uptake and adherence to long acting contraceptive (LAC) methods.

Methods: We conducted a three-month community-based qualitative assessment through 20 in-depth interviews in Fondwa, Haiti. Participants were divided into 4 groups of five: female users, female non-users, men and key community stakeholders.

Results: Based on the qualitative interviews, we found that main barriers included lack of access to family planning education and services and concerns regarding side effects and health risks, especially related to menstrual disruption and fears of infertility. Women have a constant pressure to remain fertile and bear children, due not only to social but also economic needs. As relationships are conceived as means for economic provision, the likelihood of uptake of irreversible methods (vasectomy and tubal ligation) was restricted by loss of fertility. Consequently, the discourse of family planning, though self-recognized in their favor, assumes women can afford not to bear children. This assumption should be questioned given the complexities of the other social determinants at play, all which affect the reproductive decisions made by Haitians.

Conclusions: Overall, our study indicated awareness surrounding contraception in the Haitian Fondwa community. Combining the substantial impact of birth spacing with the elevated yet unmet need for contraceptives in the area, it is necessary to address the intricacies of gender issues in order to implement successful programing. In Haiti not being able to bear a child poses a threat to economic and social survival, possibly explaining a dimension of the low uptake of LACs in the region, even when made available. For this reason, we believe IUDs (Intrauterine Devices) provide a suitable alternative, allowing the couple to comprehend all of the factors involved in decision making, thus decreasing the imbalances of power and knowledge prior to considering an irreversible alternative.

Perceived cannabis use norms and cannabis use among adolescents in the United States.

Due to changes in cannabis policies, concerns about cannabis use (CU) in adolescents have increased. The population of nonwhite groups is growing quickly in the United States. We examined perceived CU norms and their association with CU and CU disorder (CUD) for White, Black, Hispanic, Native-American, Asian-American, Native Hawaiian/Pacific Islander (NH/PI), and mixed-race adolescents. Data were from adolescents (12-17 years) in the 2004-2012 National Surveys on Drug Use and Health (N = 163,837). Substance use and CUD were assessed by computer-assisted, self-interviewing methods. Blacks, Hispanics, Native-Americans, and mixed-race adolescents had greater odds of past-year CU and CUD than Whites. Among past-year cannabis users (CUs), Hispanics and Native-Americans had greater odds of having a CUD than Whites. Asian-Americans had the highest prevalence of perceived parental or close friends' CU disapproval. Native-Americans and mixed-race adolescents had lower odds than Whites of perceiving CU disapproval from parents or close friends. In adjusted analyses, adolescent's disapproval of CU, as well as perceived disapproval by parents or close friends, were associated with a decreased odds of CU in each racial/ethnic group, except for NHs/PIs. Adolescent's disapproval of CU was associated with a decreased odds of CUD among CUs for Whites (personal, parental, and close friends' disapproval), Hispanics (personal, parental, and close friends' disapproval), and mixed-race adolescents (personal, close friends' disapproval). Racial/ethnic differences in adolescent CU prevalence were somewhat consistent with adolescents' reports of CU norm patterns. Longitudinal research on CU health effects should oversample nonwhite adolescents to assure an adequate sample for analysis and reporting.

Variation in Inpatient Rehabilitation Utilization After Hospitalization for Burn Injury in the United States.

Approximately 45,000 individuals are hospitalized annually for burn treatment. Rehabilitation after hospitalization can offer a significant improvement in functional outcomes. Very little is known nationally about rehabilitation for burns, and practices may vary substantially depending on the region based on observed Medicare post-hospitalization spending amounts. This study was designed to measure variation in rehabilitation utilization by state of hospitalization for patients hospitalized with burn injury. This retrospective cohort study used nationally collected data over a 10-year period (2001 to 2010), from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SIDs). Patients hospitalized for burn injury (n = 57,968) were identified by ICD-9-CM codes and were examined to see specifically if they were discharged immediately to inpatient rehabilitation after hospitalization (primary endpoint). Both unadjusted and adjusted likelihoods were calculated for each state taking into account the effects of age, insurance status, hospitalization at a burn center, and extent of burn injury by TBSA. The relative risk of discharge to inpatient rehabilitation varied by as much as 6-fold among different states. Higher TBSA, having health insurance, higher age, and burn center hospitalization all increased the likelihood of discharge to inpatient rehabilitation following acute care hospitalization. There was significant variation between states in inpatient rehabilitation utilization after adjusting for variables known to affect each outcome. Future efforts should be focused on identifying the cause of this state-to-state variation, its relationship to patient outcome, and standardizing treatment across the United States.

Nurse-led behavioral management of diabetes and hypertension in community practices: a randomized trial.

BACKGROUND: Several trials have demonstrated the efficacy of nurse telephone case management for diabetes (DM) and hypertension (HTN) in academic or vertically integrated systems. Little is known about the real-world potency of these interventions. OBJECTIVE: To assess the effectiveness of nurse behavioral management of DM and HTN in community practices among patients with both diseases. DESIGN: The study was designed as a patient-level randomized controlled trial. PARTICIPANTS: Participants included adult patients with both type 2 DM and HTN who were receiving care at one of nine community fee-for-service practices. Subjects were required to have inadequately controlled DM (hemoglobin A1c [A1c] ≥ 7.5%) but could have well-controlled HTN. INTERVENTIONS: All patients received a call from a nurse experienced in DM and HTN management once every two months over a period of two years, for a total of 12 calls. Intervention patients received tailored DM- and HTN- focused behavioral content; control patients received non-tailored, non-interactive information regarding health issues unrelated to DM and HTN (e.g., skin cancer prevention). MAIN OUTCOMES AND MEASURES: Systolic blood pressure (SBP) and A1c were co-primary outcomes, measured at 6, 12, and 24 months; 24 months was the primary time point. RESULTS: Three hundred seventy-seven subjects were enrolled; 193 were randomized to intervention, 184 to control. Subjects were 55% female and 50% white; the mean baseline A1c was 9.1% (SD = 1%) and mean SBP was 142 mmHg (SD = 20). Eighty-two percent of scheduled interviews were conducted; 69% of intervention patients and 70% of control patients reached the 24-month time point. Expressing model estimated differences as (intervention--control), at 24 months, intervention patients had similar A1c [diff = 0.1 %, 95 % CI (-0.3, 0.5), p = 0.51] and SBP [diff = -0.9 mmHg, 95% CI (-5.4, 3.5), p = 0.68] values compared to control patients. Likewise, DBP (diff = 0.4 mmHg, p = 0.76), weight (diff = 0.3 kg, p = 0.80), and physical activity levels (diff = 153 MET-min/week, p = 0.41) were similar between control and intervention patients. Results were also similar at the 6- and 12-month time points. CONCLUSIONS: In nine community fee-for-service practices, telephonic nurse case management did not lead to improvement in A1c or SBP. Gains seen in telephonic behavioral self-management interventions in optimal settings may not translate to the wider range of primary care settings.

Ink Under the Fingernails: Making Print in Nineteenth-Century Mexico City

This dissertation examines Mexico City’s material politics of print—the central actors engaged in making print, their activities and relationships, and the legal, business, and social dimensions of production—across the nineteenth century. Inside urban printshops, a socially diverse group of men ranging from manual laborers to educated editors collaborated to make the printed items that fueled political debates and partisan struggles in the new republic. By investigating how print was produced, regulated, and consumed, this dissertation argues that printers shaped some of the most pressing conflicts that marked Mexico’s first formative century: over freedom of expression, the role of religion in government, and the emergence of liberalism. Printers shaped debates not only because they issued texts that fueled elite politics but precisely because they operated at the nexus where new liberal guarantees like freedom of the press and intellectual property intersected with politics and patronage, the regulatory efforts of the emerging state, and the harsh realities of a post-colonial economy.

Historians of Mexico have typically approached print as a vehicle for texts written by elites, which they argue contributed to the development of a national public sphere or print culture in spite of low literacy levels. By shifting the focus to print’s production, my work instead reveals that a range of urban residents—from prominent printshop owners to government ministers to street vendors—produced, engaged, and deployed printed items in contests unfolding in the urban environment. As print increasingly functioned as a political weapon in the decades after independence, print production itself became an arena in struggles over the emerging contours of politics and state formation, even as printing technologies remained relatively unchanged over time.

This work examines previously unexplored archival documents, including official correspondence, legal cases, business transactions, and printshop labor records, to shed new light on Mexico City printers’ interactions with the emerging national government, and reveal the degree to which heated ideological debates emerged intertwined with the most basic concerns over the tangible practices of print. By delving into the rich social and cultural world of printing—described by intellectuals and workers alike in memoirs, fiction, caricatures and periodicals— it also considers how printers’ particular status straddling elite and working worlds led them to challenge boundaries drawn by elites that separated manual and intellectual labors. Finally, this study engages the full range of printed documents made in Mexico City printshops not just as texts but also as objects with particular visual and material qualities whose uses and meanings were shaped not only by emergent republicanism but also by powerful colonial legacies that generated ambivalent attitudes towards print’s transformative power.

American Manna: Religious Responses to the American Industrial Food System

“American Manna: Religious Responses to the American Industrial Food System” is an investigation of the religious complexity present in religious food reform movements. I conducted ethnographic fieldwork at four field sites. These field sites are a Jewish organic vegetable farm where the farmers begin their days with meditation, a Christian raw vegan diet center run by Messianic Jews, a Christian family that raises their cattle on pastures and sends them to a halal processing plant for slaughter, and a Jewish farm where Christian and Buddhist farm staff helped to implement shmita, the biblical agricultural sabbatical year.

The religious people of America do not exist in neatly bound silos, so in my research I move with the religious people to the spaces that are less clearly defined as “Christian” or “Jewish.” I study religious food reformers within the framework of what I have termed “free-range religion” because they organize in groups outside the traditional religious organizational structures. My argument regarding free-range religion has three parts. I show that (1) perceived injustices within the American industrial food system have motivated some religious people to take action; (2) that when they do, they direct their efforts against the American food industry, and tend to do so outside traditional religious institutions; and finally, (3) in creating alternatives to the American food industry, religious people engage in inter-religious and extra-religious activism.

Chapter 1 serves as the introduction, literature review, and methodology overview. Chapter 2 focuses on the food-centered Judaism at the Adamah Environmental Fellowship at the Isabella Freedman Jewish Retreat Center in Falls Village, CT. In Chapter 3, I discuss the Hallelujah Diet as prescriptive literature and as it is put into practice at the Hallelujah Diet Retreat Center in Lake Lure, NC. Chapter 4 follows cows as they move from the grassy hills of Baldwin Family Farms in Yanceyville, NC to the meat counter at Whole Foods Markets. In Chapter 5, I consider the shmita year, the biblical agricultural sabbatical practice that was reimagined and implemented at Pearlstone Center in Baltimore, MD during 2014-2015. Chapter 6 will conclude this dissertation with a discussion of where religious food reform has been, where it is now, and a glimpse of what the future holds.

Unnatural History: Ecological Temporality in Post-1945 American Literature

While environmental literary criticism has traditionally focused its attention on the textual representation of specific places, recent ecocritical scholarship has expanded this focus to consider the treatment of time in environmental literature and culture. As environmental scholars, activists, scientists, and artists have noted, one of the major difficulties in grasping the reality and implications of climate change is a limited temporal imagination. In other words, the ability to comprehend and integrate different shapes, scales, and speeds of history is a precondition for ecologically sustainable and socially equitable responses to climate change.

My project examines the role that literary works might play in helping to create such an expanded sense of history. As I show how American writers after 1945 have treated the representation of time and history in relation to environmental questions, I distinguish between two textual subfields of environmental temporality. The first, which I argue is characteristic of mainstream environmentalism, is disjunctive, with abrupt environmental changes separating the past and the present. This subfield contains many canonical works of postwar American environmental writing, including Aldo Leopold’s A Sand County Almanac, Edward Abbey’s Desert Solitaire, Annie Dillard’s Pilgrim at Tinker Creek, and Kim Stanley Robinson’s Science in the Capital trilogy. From treatises on the ancient ecological histories of particular sites to meditations on the speed of climate change, these works evince a preoccupation with environmental time that has not been acknowledged within the spatially oriented field of environmental criticism. However, by positing radical breaks between environmental pasts and environmental futures, they ultimately enervate the political charge of history and elide the human dimensions of environmental change, in terms both of environmental injustice and of possible social responses.

By contrast, the second subfield, which I argue is characteristic of environmental justice, is continuous, showing how historical patterns persist even across social and ecological transformations. I trace this version of environmental thought through a multicultural corpus of novels consisting of Ralph Ellison’s Invisible Man, Ishmael Reed’s Mumbo Jumbo, Helena María Viramontes’ Under the Feet of Jesus, Linda Hogan’s Solar Storms, and Octavia Butler’s Parable of the Sower and Parable of the Talents. Some of these novels do not document specific instances of environmental degradation or environmental injustice and, as a result, have not been critically interpreted as relevant for environmental analysis; others are more explicit in their discussion of environmental issues and are recognized as part of the canon of American environmental literature. However, I demonstrate that, across all of these texts, counterhegemonic understandings of history inform resistance to environmental degradation and exploitation. These texts show that environmental problems cannot be fully understood, nor environmental futures addressed, without recognizing the way that social histories of inequality and environmental histories of extraction continue to structure politics and ecology in the present.

Ultimately, then, the project offers three conclusions. First, it suggests that the second version of environmental temporality holds more value than the first for environmental cultural studies, in that it more compellingly and accurately represents the social implications of environmental issues. Second, it shows that “environmental literature” is most usefully understood not as the literature that explicitly treats environmental issues, but rather as the literature that helps to produce the sense of time that contemporary environmental crises require. Third, it shows how literary works can not only illuminate the relationship between American ideas about nature and social justice, but also operate as a specifically literary form of eco-political activism.

In Whose Image: The Emergence, Development, and Challenge of African-American Evangelicalism

The current era of American Christianity marks the transition from a Western, white-dominated U.S. Evangelicalism to an ethnically diverse demographic for evangelicalism. Despite this increasing diversity, U.S. Evangelicalism has demonstrated a stubborn inability to address the entrenched assumption of white supremacy. The 1970s witnessed the rise in prominence of Evangelicalism in the United States. At the same time, the era witnessed a burgeoning movement of African-American evangelicals, who often experienced marginalization from the larger movement. What factors prevented the integration between two seemingly theologically compatible movements? How do these factors impact the challenge of integration and reconciliation in the changing demographic reality of early twenty-first Evangelicalism?

The question is examined through the unpacking of the diseased theological imagination rooted in U.S. Evangelicalism. The theological categories of Creation, Anthropology, Christology, Soteriology, and Ecclesiology are discussed to determine specific deficiencies that lead to assumptions of white supremacy. The larger history of U.S. Evangelicalism and the larger story of the African-American church are explored to provide a context for the unique expression of African-American evangelicalism in the last third of the twentieth century. Through the use of primary sources — personal interviews, archival documents, writings by principals, and private collection documents — the specific history of African-American evangelicals in the 1960s and 1970s is described. The stories of the National Black Evangelical Association, Tom Skinner, John Perkins, and Circle Church provide historical snapshots that illuminate the relationship between the larger U.S. Evangelical movement and African-American evangelicals.

Various attempts at integration and shared leadership were made in the 1970s as African-American evangelicals engaged with white Evangelical institutions. However, the failure of these attempts point to the challenges to diversity for U.S. Evangelicalism and the failure of the Evangelical theological imagination. The diseased theological imagination of U.S. Evangelical Christianity prevented engagement with the needed challenge of African American evangelicalism, resulting in dysfunctional racial dynamics evident in twenty-first century Evangelical Christianity. The historical problem of situating African American evangelicals reveals the theological problem of white supremacy in U.S. Evangelicalism.