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Dugassa B. Structural inequality (SI) and underdevelopment of public health conditions: the experiences of Oromo people in Ethiopia. HPHR. 2021;30
DOIL:10.54111/0001/DD2
Individuals and a population’s health status result from the multi-layered and complex constructs of the social determinants of health[1]. Building such multi-layered social conditions and translating knowledge into practice requires meticulous efforts. Identifying situations that hinder progress and tackling them at the “upstream level” are quintessential.
Using the upstream and downstream public metaphor, I explore the pathways in which structural inequality (SI) has contributed to the underdevelopment of public health in Oromia. Analyses are made based on data collected for my Ph.D. thesis and afterward.
SI hinders the capacity to shape the future development of public health in Oromia in multiple ways. Those ways include: a) impeding the building of social, economic, political, cultural, and environmental capacities; b) civic and criminal injustice; c) unfair distribution of opportunities and risks; d) neglecting and aggravating social problems. Identifying and addressing the SI that hinders developing the social factors that influence population health should be considered as one of the core public health strategies.
In societies where SI is controlled, public health conditions are built progressively. Removing SI, and enabling Oromo people to decide on their social, economic, political, cultural, and environmental affairs helps to control and effectively manage their social conditions and create a fair distribution of social determinants of health and widening their choices. Enabling people and creating equitable social structures are essential for public health development.
Ethiopia is a multi-ethno/national empire. It was formed in the 1880s when the European empire builders provided a racist episteme, military hardware, and both military and political advisors to the Abyssinians (Holcomb and Ibsa, 1991; Jalata, 2005). The Abyssinian king at the time applied the European racist episteme and the military hardware to conquer independent peoples like the Oromos, Afars, Sidamas and others settled adjacent to them. The resource-rich, largest, and strongest national group they conquered were Oromos. The process of the colonial conquest took over thirty years of protracted and bloody wars. The colonial conquest not only created structural inequality but also legalized it and made it morally acceptable. Creating structural inequality is part of the process of allocating disproportionate privileges and burdens. For the colonized people, it creates unhealthy social conditions and hinders the capacity to be resilient.
The impacts of this protracted war of conquest were substantial. Recorded evidence and oral stories confirm that the Oromo people lost half to two-thirds of their population (Bulatovich,2000; de Salviac,1901/2005). The reasons for the depopulation include (a) indiscriminate killings, i.e., hand-breast mutilations, (b) the introduction of infectious diseases, i.e., cholera and Rinderpest virus (cattle plague); (c) slave trade; (d) widespread burning of houses and grains; (e) looting of cattle and grains; (g) mass evictions and (h) structural violence targeting the social, economic, cultural and political institutions; and (i) causing famine (Dugassa, 2008).
The Oromo[2] people are an egalitarian society. They have developed their unique civilizations. When many countries were ruled by kings and queens, the Oromo people openly elected their leaders (Legesse, 2006). When the Western societies theorized the inferiority of women and legalized gender discrimination, the Oromo people had developed a system known as Siiqqee, where women independently organized themselves and asserted their rights in society (Kumsa, 1997). When many societies proclaimed their uncontested authority over the natural world, allowed unsustainable development, and polluted our natural environments, the Oromo people stressed a direct relationship between environmental health and community health and adopted the idea of planetary health (Dugassa, 2018b). When many societies encouraged the marriage of close family members, Oromo people understood the impacts and prohibited such unions (Dugassa, 2015, 2021).
Colonial conquests and social, economic, political, and cultural subjugations either stopped, hindered, and sometimes even reversed the Oromo civilization. Instead of freely electing their leaders, the Oromo people were subjected to monarchs who falsely claimed they had come from a divine power or ruled by dictators who do not respect human rights and the rule of law. As a result, successive Ethiopian regimes denied the Oromo people from freely determining their affairs. Violating the rights of Oromo people to decide on their social, economic, political, cultural, and environmental matters hindered the development of those capacities (Sen, 1999) needed to widen their choices in life (Dugassa,2018). For example, violating social rights hindered further developing the social policies in caring for the sick and weak members of the society. Violating economic rights legalized the exploitation of human and natural resources and made dispossession of lands, evictions, and poverty acceptable. Violating political rights hindered them from developing their institutions and leadership.
The Oromo people were ruled by a system of governance that profoundly dishonored them and was entirely interested in controlling and exploiting them. Consecutive Ethiopian governments’ social policies are geared to widening the privileges of Abyssinians. When it comes to the needs of the Oromo people, their policies are either designed to weaken them or neglect their needs. Failure to understand the social processes of public health problems in Oromia leads to analytical omission. Analytical failure has implications for policymaking and practices (Farmer, 2003). In order to clearly understand the reasons for the underdevelopment of public health conditions and make plans to develop evidence-based population health policies, we need to contextualize the structural inequality.
It is impossible to fully grasp the reasons for the underdevelopment of public health in Oromia without understanding how the European empire builders provided racist theory, military weapons and personnel, and made Abyssinia a colonial state – adopting the biblical name “Ethiopia” and the policies that followed. In this paper, using the data collected for my Ph.D. thesis and afterward, I explore structural inequality, economic exploitations, denial of cultural rights, criminalization of political activism, violating voting rights, i.e., the right to develop leadership, the unfair distribution of privileges and risks and reveal the ways those malign social conditions have contributed to the underdevelopment of public health. As I explore those social conditions in which the Oromo people have lived for over a century, I show how these conditions have limited the opportunity to shape their future and choices in life.
This paper consists of four major parts. In the first part, I outline the research objectives, define some of the terms used, and introduce the significance of structural inequality in Ethiopia. In the second part, using the upstream and downstream public health metaphor, I explore and reveal the ways structural inequality has hindered the development of the social, economic, political, cultural, and environmental capacities of the Oromo people. The third part explores the ways structural inequality legalized the unfair distribution of privileges and risks and the ways in which the civic and criminal justice system widened SI and contributed to public health underdevelopment. The last part covers discussions and conclusions.
Extreme poverty, food insecurity, scarcity of clean water, homelessness, high illiteracy, human rights violations, lack of access to the required necessities of life, and easily preventable diseases are widespread in Oromia. They have resulted from the social conditions that inequitable social structures have created. The primary objective of this paper is applying the “upstream” and “downstream” public health metaphors and exploring the ways in which structural inequality is hindering Oromo people from developing public health conditions. The secondary objective is generating empirical evidence on the close relationships between structural inequality and the underdevelopment of public health, providing theoretical and practical reasons for the “upstream” public health interventions.
In this paper, public health[3] is understood as “the art and science of preventing disease, prolonging life, and promoting health through the organized efforts of society” (WHO,1998). The Ottawa Charter for Health Promotion (WHO,1986) described health promotion as “the process of enabling people to increase control over and to improve their health.” The WHO definition underlined two critical points relevant to the issues explored in this paper. The first notable point is that preventing diseases, prolonging life, and promoting health encompass both the arts and sciences. The second point is that those arts and sciences need to develop through continuous and organized efforts of society. The development of public health refers to creating social protection and health promotion factors. Those factors include having food security, clean water, reasonable housing, timely vaccinations for major infectious diseases, safe workplaces, moderate-income, education, and health care services. The development of those health gradients goes beyond individuals’ efforts; they require communities and states to strive continuously. Developing those indispensable arts and sciences require Oromo people to freely organize, coordinate their human and natural resources, assess their needs, formulate policy directions, and assure implementation.
SI is a social construct that defines the distribution of goods and privileges. It refers to the burdens placed on the social background of the group. SI is the relationships between societies measured in terms of distribution of power, wealth, privileges, risks, personal liberty, and opportunities (Royce, 2018). SI focuses more on relationships between groups of people and emphasizes addressing the unfair distribution of goods and services. Equitable social structure heals social wounds, promotes activities that strengthen public health capacities and services, and creates conditions under which people can identify their needs and address them. Violations of the collective rights of people, i.e., the right to freely define their social, economic, political, cultural, and environmental affairs, creates and widens SI. If we closely look at the impacts of violations of the rights of Oromo people to freely define their affairs through the structural lenses, we can see that those violations have consequently hindered the development of their capacities (Dugassa,2018).
Individuals and a population’s health status result from a multi-layered and complex construct of the social determinants of health (WHO,2010). Epigenetic science reveals that our growth and development are also influenced by our parents’ and grandparents’ growth and development. The health status of our children and grandchildren is connected to the generation before us. Building those multi-layered social conditions for Oromos and others requires protracted efforts (Rozek; Dolinoy et al., 2014; Tiffon, 2018). Research from the past two decades shows that developing evidence-based public health policies and robust health promotion strategies necessitate removing structural inequalities and advancing health equity. Identifying and addressing the social structures that hinder people from developing the social conditions that influence a population’s health is necessary in order to create the situation in which fair distributions of the social determinants of health are granted.
Public health policies involve complex, protracted, and future-oriented social programming. Public health activities change over time with changes in social values and scientific progress. This necessitates developing public health institutions, researchers, and policymakers who are systemic thinkers (Dugassa,2020). In democratic societies, public health conditions are built progressively over time. For example, in Canada, life expectancy has improved over 35 years in the last hundred years. Thirty of those years are attributed to public health interventions and five years to medical care. Enabling people to understand and decide on their affairs and increasing control over their social conditions helps them widen their choices and foster those changes. The foundations of public health can effectively be built if human rights are respected (Mann; Gruskin et al., 1999) and structural inequalities removed. For those reasons, public health is where sciences and the arts of policymaking, and social activism converge. Closely looking at SI may help reorient our thinking in understanding the problems and setting policy directions. To trace the causes of structural inequalities, I review a few historical facts.
The impacts of European colonialist racist theories and practices and how they create inequitable social structures have been widely discussed (Loury,2002). Racist thinking provided theoretical reasoning for structural violence and structural inequalities and was responsible for the slave trade, colonialism, genocide, and health disparities[4], pathogenic social relations, and hindering capacity building[5].
In the Hutu and Tutsi conflict case, the literature partly covered the effects of the European racist theories among three African indigenous peoples. In the Tutsi, Hutu, and Twa case, European empire builders applied racist policies to their colonial lands such as Rwanda and Burundi. Colonizers applied the theory of racial hierarchy and used policies of differential treatments. This racial theory presented the idea that the Tutsi people belonged to the Hamitic[6] family and were racially superior to the Hutu and Twa because the last two belonged to a group not mentioned in their Holy Book.- the Bible. This theory made the colonizers first class, the Tutsi second class, and Hutu and Twa third-class citizens. The Tutsi were assigned to be intermediate between the colonizers and the Hutu and Twa people. The German and Belgian colonizers consequently enforced that racial theory. This has created unhealthy social relations between the Tutsi, Hutu, and Twa people. The inequitable social structure has widened competing interests between those groups (Mamdani,2001).
In the 1960s, when the anti-colonial movement was growing in Africa, the Tutsis, who had access to Western education, started a campaign against the colonizers. This made the Belgian colonialists unhappy. The colonialists applied the divide and rule policy and wanted to bring the Hutus on their side. The colonizers massively converted the Hutus to Catholicism. Following that, they started favoring the Hutu—implying they are now worshiping our divine power and are “civilized like us.” The policy shift widened conflicts between the Hutu and Tutsi and created reasons for the 1995 Tutsi genocide [7]. Racist theories normalize and legalize certain racial/cultural groups’ dehumanization, exploitation, and differential treatments. It is evident that racist ideology crosses borders and creates inequitable social structures and pathologic social relations.
The two African countries never colonized by Europeans are Liberia and Ethiopia – formerly Abyssinia. The founders of Liberia[8] were runaway enslaved peoples from the U.S.A. (see Liberian historical Events). The runaway enslaved people brought with them Christianity, the English language, and even copied the American flag[9]. In the state formation, those runaway enslaved people established domination over those who never left Africa. Since then, the U.S.A has exercised a moral protectorate over Liberia.
Abyssinians are one of the first Christian groups[10], and through the religious ideas and institutions, for centuries they have been bonded to the European Christian world. This makes Abyssinia and Liberia the only two African countries that practiced Christianity when the European colonizers invaded Africa. They both escaped colonization. They did not escape colonialism by chance or by their military power. They escaped conquest because they practiced Christianity; the colonialists believed that they were “civilized” like them and had no moral justification for conquering them. When it comes to Abyssinia, the Semitic-Hamitic racist theory was applied. In the conviction that Semitic was racially superior to Hematic, the colonialists provided everything needed to make Abyssinia a colonial state.
Knowledge is socially constructed. What is authentic and valid for one cultural group is not necessarily true for others (Berger & Luckmann,1966). European empire builders believed that they were racially and culturally superior to others. They claimed to possess only sound knowledge. Things that were not consistent with their culture and worldview were presented as void and inferior. Those deep-seated views informed racially biased social cognitive processes to be sustainably reproduced (Smith, 1999). That short-sighted and discriminatory cognitive behavior guided their colonial agendas and policies (Dugassa, 2012). Colonial formal and informal education validated racist theories and practices and created inequitable structures. Colonial education strives to convince the colonized that their experiences are void and their experiences are invalid; impoverishment, malnutrition, homelessness, and diseases have resulted from their own faults or natural phenomena (Dugassa, 2011).
The experiences of the Oromo people clearly show that theory informed practice and practice guided theory. The European empire builders initially provided Abyssinia with racist theoretical reasons and military hardware and military advisers to conquer the Oromo people. Based on racist ideas, the Oromo people and their worldviews have been dishonored. At the end of the 1880s, in the formation of the present Ethiopian state, the Oromo people were conquered and incorporated (Holcomb and Ibsa, 1991; Jalata, 2005). Since then, Oromo people have been denied the right to decide on their social, economic, political, cultural, and environmental affairs. The racist theory and conquest established and legalized an inequitable social structure. The policies of successive Ethiopian regimes focused on maintaining and widening those inequitable structures. Intrinsically, the Oromo people have experienced what Amartya Sen (Sen, 1999) called “un-freedom,” powerlessness, enduring social inequality, and injustice.
The Ethiopian empire was formed in the 1880s when the Abyssinian King Menelik II invaded an independent people adjacent to them (Holcomb and Ibsa, 1991; Jalata, 2005). The colonial conquest and the policies developed thereafter violated the rights of the Oromo people to decide on their social, economic, political, cultural, and environmental affairs. Violations of those rights created and widened SI. The SI legalized and normalized differential treatments. For example, although the Oromo language is widely spoken in Ethiopia and the Horn of Africa, Amharic is the only official language for the Federal government. The Ethiopian language policy subsidized the development of Amharic literature and inhibited the growth of Oromo literature. The inequality created by the language policy manifests even today.
When the Oromo people were conquered, most of them practiced an indigenous religion – Waqeffanna. However, consistent with the empire builders’ biological/cultural racist views, Orthodox Christianity was legalized as the state religion. On the pretext that resources were needed for church building and services, the Ethiopian government legalized handing one-third of the Oromo lands to the church and one-third to the crown. This led to the eviction of the Oromo people from their lands or made them serfs and sharecroppers for the Orthodox church, crown, and Abyssinian elites. The Ethiopian legal system and educational curriculum are also consistent with Abyssinian political culture. In effect, the education and legal system criminalized Oromo political activism and the demand for social justice[11]. Those policies have created and widened social inequality.
Traditionally the main emphasis for improvements in public health has been controlling biological hazards. As we learned how chemical pollutants contributed to diseases and disability, the need to control those hazards was added (Rasen, 1993). In the last three decades, our understanding of the social determinants of health informed us that toxic social environments are as hazardous as biological and chemical ones. The distributions of the social determinants of health are carried out by political power. Growing evidence shows inequalities have a profound impact on social wellbeing and vulnerability (WHO, 2008). Lack of participation in the community’s social, economic, and political affairs causes differential access to the social determinants of health. Hence, closely looking at the causes of SI and advancing social justice should be part of health promotion.
Inequality is not fated by nature; instead it is created by visible and invisible hands (Fisher; Hout et al., 1996). Where there is social inequality, marginalized groups are bombarded with teachings intended to convince them that their social problems are the consequence of their faults rather than structural inequalities. Schooling heavily determines the types of jobs they can work at and the income they make in adulthood. Marginalized students are conditioned to accept what the colonial educational curriculum offers them. In countries like Ethiopia, where SI is built and maintained, the school curriculum becomes a powerful tool used to maintain and resist domination (Dugassa, 2011). Policymaking is not solely evidence-based and impartial. As Linda Smith said clearly, social science research is based upon ideas, beliefs, and theories about the social world (Smith,1999). Cognitively, knowledge is a form of thinking, and thinking is a form of doing (Gasset,2002).
Policymaking constitutes deciding the types of social problems that require full investigation and interventions. It includes selecting the works and products that need to be subsidized or heavily taxed. It also influences the rewards individuals receive for attaining their position in society. Social structure informs and shapes the policy makers’ views and perspectives – inevitably guiding the policy directions (Dugassa, 2012). To take a critical look at how the SI impeded the development of public health in the following section, I introduce the concept of social determinants of health and the upstream and downstream public health metaphor.
Personal health and a population’s health result from a multi-layered and complex construct of the social determinants of health. The social determinants of health might vary from country to country. However, the primary known social determinants of health are food security, clean water, reasonable housing, education, income, social status, employment, safe working conditions, livable physical environments, social supports, gender, culture, racism/ethnic discrimination, childhood experiences, and access to health care services (WHO, 2010). Some of the social determinants of health unique to the Oromo people include discriminatory language policy, human rights violations, denial of development of leadership, institutions, and the absence of independent media (Dugassa, 2006, 2012, 2016).
The socio-economic factors that influence individual and population health are well known. Further widening our knowledge, epigenetic science has revealed that our growth and development are influenced by the growth and development of our parents and grandparents. The health status of our children and grandchildren are connected to the health status of generation before us. Building those multi-layered social conditions for the health of future generations requires meticulous efforts. This understanding suggests the need to identify and address the social structures that hinder the development of the social and economic factors that influence population health.
Analyzing the ways SIs were built and maintained helps us understand the pathways in which the development of those essential socio-economic conditions are deterred. Making such analyses helps us understand the ways in which they have contributed to the underdevelopment of public health.
Social constructionists have long argued that health and diseases are distributed socially rather than bio-genetically (Bury and Gabe, 2004). If health and diseases have sociological origins, leaving the study of health and disease to clinical medicine alone makes the social problems bio-medical ones. This makes our understanding of health and illness incomplete and prevention and treatment ineffective. As a public health researcher and practitioner, my works focused on looking upstream and identifying the social causes of the problems rather than addressing them at the downstream levels. Establishing the social causes of health and diseases is essential in promoting health and prevention of diseases. The emancipation of people is a crucial tool needed to address public health problems. To make health promotion and disease prevention sustainable and reveal how a SI hinders the development of public health, I want to present it in the form of a metaphor.
To give depth analyses on the relationships between SI and the underdevelopment of public health, I give the classic public health metaphor[12]. Imagine a river is swiftly flowing from a highland region of the country to the lowland region. The people in the lowland area noticed children drowning by the shore of a swiftly flowing river. At one point, they heard the cries of drowning children. The rescue team jumped into the dirty water. They swam against the strong current and reached the struggling children. They were able to hold the hands of some of the struggling children, pull them out to the shore and revive them. For some of those children, it was too late. Soon after, they heard the older men and older women’s cries for help. They jump into the river, swim against the strong current, and get to the older men and women. They grabbed them and carefully pulled them out of the river and revived some of them. They succeeded in saving some older men and women but not others. Before these rescue groups could have any break, they hear another cry for help. This time, it is the sound of drowning younger women. The rescuers jumped into the river fighting against the strong current and reached the women and, as quickly as possible, pulled them out and revived them. Just as some of the women started to breathe independently, they heard another cry for help. At this point, the rescuers were exhausted; their duty became just jumping in and rescuing. They started to ask themselves what was going on upstream, and the rescuers decided to find out who or what was upstream pushing people into the river. Since then, they decided to address problems at their sources.
In Oromia, human rights violations, poverty, malnutrition (Dugassa, 2004), endemic and epidemic diseases (Dugassa,2006) are ravaging the country. Food insecurity, scarcity of clean water, environmental degradation, competition for resources, and displacement of people is widespread. The exploitation of human and natural resources, political persecutions, and reduced social participation are becoming endemic problems. Those social problems are further aggravated by climate change (Dugassa,2021a). Those conditions are affecting the physical, emotional and cognitive development of people. Like the swiftly flowing river, they are washing away the capacity of the Oromo people to develop their public health structures. Those conditions are eating away the social and economic protective factors necessary to develop and strengthen public health. Those in charge of current public health policies in Oromia/Ethiopia are not prepared to think and act at the upstream level. This must change and stakeholders must discuss the relationships between SI, social determinants of health, and public health underdevelopment.
From the early 1900s to 1975, Abyssinian institutions such as the Crown, Orthodox church, and Abyssinian individuals owned over 70% of the farmlands in Oromia. The Oromo people became serfs and sharecroppers on their ancestral lands, and they had to give a quarter to three-quarters of their harvests to the Abyssinian landlords (Leta,1999; Jalata, 2005). Millions were evicted from their lands and conditioned to live in poverty. Some of them were pushed into lowland regions – malaria-prone zones where the scarcity of water is high. The Oromo people paid taxes without having any services or representation (Dugassa, 2008).
From 1975 to the present, by decree, the Ethiopian government made all land belongs to the state. During the military government (1975-91), in the pretext of collective farming policies, the Oromo people were forced to dismantle their villages to build planned towns. Building newer and bigger villages was implemented with no adequate planning for housing, access to clean water, and other necessary sanitary conditions. The bigger villages were overcrowded and created favorable conditions for microorganisms. In those unhealthy conditions, many children died, and people lost their cattle to infections. The Oromo people were forced to sell their harvests at a fixed price to the government. The government used them to feed its military and city dwellers. The income generated from the resale of grain was used to purchase military equipment from the U.S.S.R. Besides that, Oromo young men were conscribed to the war front. Many of them died there, and others returned to their villages injured, and with no compensation. This further aggravated poverty. When the war abruptly ended, over half a million militias were sent back to their villages. Many of them were HIV positive and unwittingly spread the virus to small towns and hard-to-reach villages (Dugassa,2008).
In 1991 when the Tigray People’s Liberation Front (TPLF) controlled the state, the power shifted from one Abyssinian group to another. The power shift from Amhara domination to Tigray did not bring significant changes. The TPLF dominated government developed policies that enriched Tigray elites and made corruption the norm. During those years, the exploitation of human and natural resources further intensified. With no or little compensation, the Oromo people were massively evicted[13], which further aggravated their poverty level and homelessness. In the eviction of the Oromo people, the Ethiopian government, the local and international corporations, politically powerful individuals, and even religious institutions were involved. Besides, the TPLF monopolized the supply of fertilizer and imposed quotas on farmers in the name of improving productivity. The TPLF charged farmers too much for the fertilizer. There are cases where farmers’ harvests could not even pay for fertilizers. Farmers were forced to pay the bill by selling their cattle (Dugassa, 2008).
The word culture is derived from the Latin word “cultura”/ “cultus,” which means care or cultivate. Culture cultivates and gives blueprints for action, shapes ideas, and informs morality, normality, and values. According to (Hofstede and Hofstede, 2010), culture has eight essential functions: (1) Topical—social organizations, religion, and economics; (2) Historical: a social heritage that is passed on to future generations; (3) Behavioral: shared and learned human behavior; (4) Normative: ideas, values, or rules for living; (5) Functional: ways humans understand and solve social problems and adapt; (6) Mental: learned habits, normative definition; (7) Structural: interrelated ideas, symbols, or behaviors; and (8) Symbolic: arbitrarily assigned meaning shared by society. Those functions are essential for societies so they can reproduce themselves socio-culturally, biologically and build their social conditions for better health. However, colonialists openly claim that they are racially and culturally superior and boldly seek to eliminate the colonized culture. The question is, what happens when the right to develop those essential functions is taken away. From the experiences of the Oromo people, the violations of cultural rights have hindered the development of cultural capacities such as educational attainments and problem solving skills (Dugassa,2006, 2016).
The UN covenants recognize cultural rights. Recognizing that human rights are derived from the inherent dignity of the human person and the equal and inalienable rights of all members of the human family, the International Covenants of Economic, Social, Political and Cultural Rights (see ICESCR) states in Article 1, “All peoples have the right of self-determination. By virtue of that right they freely determine their political status and freely pursue their economic, social and cultural development”. The ICESPC charter also recognizes the right to the highest attainable standard of health. The 2000 UN Economic Social Council explicitly states that substantive issues arising in implementing this right require equal and timely access to essential preventive, curative, and rehabilitation health services. These provisions include screening, treatment, and prevention of disabilities. Ethiopia has ratified those charters.
The population of Oromos represents 40 to 50 percent, and Amhara represents 20 to 25 percent of people in Ethiopia. The Oromo language is widely spoken as a mother tongue and lingua-franca in Ethiopia, Kenya, Djibouti, Somalia, and Uganda. However, the official language of the Ethiopian federal government is Amharic. When it comes to the Ethiopian federal government employment, 18% are Oromos, 50% are Amhara, 8% are Tigray, and 4% are Gurage. The SI that has been going on for over a century has favored Amharic speakers and given them better job opportunities. Instead of holding 20 to 25 percent positions, they took over 50 percent. Employment in the federal government also disproportionally favors the Tigray and Gurage (Midega, 2014). I also noted (Dugassa, 2006, 2016) that the Ethiopian public health education and broadcasting services are predominantly transmitted in the Amharic language. Those policies denied the Oromo people timely public health information such as the risks of HIV/AIDS. Lack of information has exposed the Oromo people to unnecessary risks and easily preventable deaths.
Equitable distribution of access to information are elements of social justice. One of the methods in which the SI is harming the Oromo people is denying them access to information. As I have elaborated in one of my works (Dugassa, 2016), access to independent media is one of the social determinants of health. The more we hear news and news analyses, the more we collect information and use it as data. The more we analyze data and synthesize it, the more we use it in knowledge construction. We use the knowledge to identify opportunities and risks. Limiting the Oromo people having access to information denies them the right to see and understand when opportunities come and when threats emerge.
Colonial conquests are always followed by controlling the colonized people’s affairs. If political rights are respected, the group can develop its own social, economic, and cultural capacity. As I mentioned above, political rights are one of the rights the UN covenants have recognized (see ICESCR). Political rights include voting rights and the right to the development of institutions and leadership. The Oromo people have been denied those fundamental rights necessary to protect their inherent dignity, advance their safety, and widen their choices in life. Why are the Oromo people denied voting rights and the development of leadership? What is the significance of violating voting rights and developing leadership? To answer those questions in the next section, I dive into the issues and closely explore the importance of voting rights and leadership development.
The Universal Declaration of Human Rights (see UDHR) in Article 21 states, “Everyone has the right to take part in the government of his/her country, directly or through freely chosen representatives. Everyone has the right of equal access to public service in his country”. Although Ethiopia has ratified this international covenant, it has never implemented it. Voting rights enable people to form a democratic government, where people exercise their rights directly and indirectly through a system of representation. It helps people influence agenda-setting and policy-making. The Oromo people have never been represented in the Ethiopian government. In sham elections, the government picks Abyssinian individuals who settled in Oromia or Oromo individuals forced to collaborate and help them implement their policies. Their policies primarily developed to protect the interests of the Abyssinian elites and maintain SI. Those handpicked individuals work against the Oromo interests. Instead of working to widen the choice of Oromo people, they work to control and exploit them. Oromo individuals who try to advance fair distribution of power[14] and resources are either condemned and labeled as ጠባብ -Tebabi- narrow or criminalized and killed or imprisoned.
The founding father of social medicine, Rudolph Virchow, practiced medicine, researched the cause of the typhus epidemic in Upper Silesia – a region predominantly Polish but ruled by Germans. Later on, he became a politician. Based on his experiences, he eloquently elaborated on the relationships between politics and health when he said, “medicine is a social science, and politics is nothing else but medicine on a large scale.” He pointed out what the role of medicine should look like when he said, “Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solutions; the politicians, the practical anthropologist, must find their means for their actual solution.” Furthermore, when he said, “the physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction,” he provided theoretical reasons for the contemporary public health practitioners and researchers of the need to go beyond biomedical care and advocate social reform and address the social conditions of the marginalized and the poor (Taylor and Rieger, 1985). Unfortunately, the Ethiopian government has denied the Oromo people the ability to develop their institutions and leaderships (Bulcha, 2006; Dugassa, 2012a), which has prevented them from fostering healing and making politics “a social medicine.”
The right of the Oromo people to freely vote, elect and develop their leaderships has been violated. The Oromo people are openly discriminated against, preventing them from working as civil servants. Those few who reached the high civil servant positions were also told to implement the discriminatory social policies in Oromia. For example, in the 1940s, when the Ethiopian authorities noted that Emanuel Abraham, an Oromo man, and a school director, had enrolled a few Oromo students in school, they accused him of giving more opportunities for Oromos. Those authorities brought the matter to King Haile Selassie, who accused him of the same thing. However, the data collected showed about 64 percent of the students were Amaras, and about 12 percent were Oromo nationals (Abrah, 1995). In another case, in the 1950s, General Taddesse Biru, an Oromo general who was in charge of adult education, was openly told not to make an effort to educate the Oromo people. The Ethiopian prime minister of the time justified that, saying, “the educated Oromo would overwhelm our political power” (Hassen,1993). Violating voting rights and leadership development has contributed to educational underachievement and hindered developing problem-solving skills. Knowledge is instrumental in building capacity and managing changes (Cummings and Worley, (2001). Education is one of the social determinants of health. The Ethiopian government has impeded the development of this essential determinant of health in Oromia.
Let me briefly illustrate how, in the absence of Oromo leadership, the Ethiopian government managed the 1972-75 famine. In 1972-75, Oromos in Wallo province were affected by famine. When people realized that they had no food to survive, able-bodied people decided to leave the area and migrate to fertile regions. When king Haile Selassie was informed about the famine and internal displacement of people, instead of providing them food, he ordered his military to stop their movement. The intention of the king to stop the mobility of people was to keep information from reaching others[15] and protect his image locally and globally. As a result, a quarter of a million people died (Dugassa,2006).
The military government that followed the Haile Selassie regime was no better. From 1975 to 1991, the regime adopted communist ideology and did- to Oromos- what the U.S.S.R had done to control Ukrainian nationalism. The government focused on intensifying the cultural assimilation of the Oromo people, controlling and caused mass starvation[16] (Kaplan,2003). Collective farming, villagization[17], and resettlement programs[18] massively displaced the Oromo people. As a result, Oromos lost their cattle and all their fixed properties. In addition, the government conscripted young Oromo men to the war front. Millions died there, and millions who were wounded returned home with no compensation. Most of the returned militias were HIV positive and unwittingly spread the infection to the countryside. Those acts were designed to assimilate, control and exploit the Oromo people and consolidate the state structure (Dugassa, 2008).
Public health policies should be evidence-based; however, decision-making remains political and ideological. Developing evidence-based public health policies is unthinkable without having reliable data (Hunter, 2016). Ethiopian government policymakers never considered the needs of the Oromo people (Dugassa,2018a). The Oromo people are not seen as stakeholders, and social problems that are more prevalent and severe in Oromia are left unsolved.
Let me bring two examples of neglect and provide evidence of Kaplan’s words (2003.pp4) when he said, “although the Oromos are the most numerous of Ethiopia’s peoples, they have never really mattered.” First, in the Rift Valley region of Oromia, the soil and water contain high fluoride levels, and fluorosis is endemic. The people who settled in that area adopted a nomadic lifestyle. During dry seasons they move away from the site, and during the rainy season, they go back. Also, they restrict pregnant women and young children from staying in that area. Before a scientific understanding of the causes of the problem, they have developed preventive strategies. From 1950 to the 1960s, the Ethiopian government handed this land to a Dutch company to manufacture sugar. The Oromo people were forced to permanently settle in the area where the fluoride level is high. When the Dutch children born in the area developed brown teeth, they investigated the cause and reported that it was due to high fluoride levels in the water. When the Ethiopian government and the Dutch company understood the risks of high fluoride, they filtered water for the Dutch families and Abyssinian office workers. For the rest of the population, they did not provide clean water or even inform them of the risks. In 1974, when the military government took power, they revealed the cause of this endemic problem (Dugassa,2016a).
Fluorine is a very reactive element. It easily dissolves in water and forms hydrofluoric acid. Fluoride crosses the blood-brain barrier and enters the brain. It is freely attached to calcium and accumulates in tooth enamel, bones, and brains. Accumulated fluoride causes disturbances in bone, cartilage homeostatic, enamel, and brain development. People dependent on water high in fluoride eventually develop fluorosis- a condition that alters cartilage and bone structure. They get physically disabled at the age of fifty years and lose their mobility.
High fluoride intake decreases fertility and suppresses the immune system development. Fluoride accumulates in the pineal gland, also known as the “mind’s eye,” and affects children’s cognitive development and learnability (Dugassa,2016a). The accumulated effects of losing the land and the relocation of Oromo people to high fluoride areas have been devastating. In a region where population growth doubles every two and half decades, the Karayu and Jilee clans’ population has significantly declined (Dugassa,2016a). The Ethiopian government has not addressed this critical endemic public health problem.
The second case of apparent neglect is housing. Housing is one of the major determinants of health. Houses are essential to a) protect people from extreme heat and cold; b) protect people from human and animal intruders; c) minimize unnecessary heat losses from the body; c) prevent chemical and biological pollutants; d) regulate daylight; e) prevent direct sunlight exposure and the risk of UV radiation; f) provide adequate illumination and light when needed; g) protect people from excess noises; h) create sufficient space for exercise and for children to play; i) create necessary sanitary conditions; j) prevent risks of infectious and chronic diseases and j) maintain privacy. Adequate housing is one of the essentials needed to enhance population health.
In Oromia, most of the houses were built the way they had been for centuries. The importance of designing homes to reduce injuries, control biological and chemical pollutants and reduce noise has received long-standing attention (Krieger and Higgins,2002). This vital knowledge informed autonomous societies to make continuous efforts and guarantee incremental changes in building design and materials used in the construction. However, in Oromia, houses are mainly built from wood, grass, and soil. When the populations were small, people settled in the dispersed areas. At that time, nature controlled the biological and chemical contaminants and minimized the impacts of unsanitary conditions. However, when the density of the population is practically tripled or quadrupled, managing unsanitary conditions goes beyond the capacity of nature. Building healthy housing and neighborhoods usually necessitate state interventions.
Primary prevention methods to respiratory and food-water borne diseases are good hygiene: reasonable housing, good drainage, clean water supply, and streets. Damp houses provide favorable conditions for respiratory viruses, molds, and other pathogenic microorganisms responsible for respiratory and other diseases (Krieger and Higgins,2002). During rainy seasons, the materials used to build houses absorb water. High humidity in high temperate zones creates favorable conditions for the growth and development of microorganisms. Those microorganisms decompose wood, grasses, and organic materials in the soil and produce hazardous chemicals. During the dry seasons, those building materials quickly catch fire and put the whole community at risk. The Ethiopian government has made no effort to improve the ways houses are built and maintained. Instead of improving the design and building of energy-efficient homes, providing better sanitary conditions such as enhancing clean water supply, drainage, sewage, fresh food storage, and other key health indicators, the government has acted indifferently.
The SI built upon colonial conquest has created a criminal and civil legal system that consolidates those structures. Overtly and covertly, the Ethiopian criminal and civil justice systems are discriminatory towards the Oromo people. As I mentioned earlier, until 1975, Abyssinian institutions such as the crown and the Church and their elites owned seventy percent of farmlands in Oromia. Most of the land dispossessions occurred through formal decrees. There are many cases when Abyssinian elites used their legal system to take Oromo land. When Abyssinian elites see fertile lands suitable for farming and easy accessibility for transportation, they claim them without any justification. When Oromo individuals refuse to concede, the Abyssinian elites take the case to their court. At court, the Oromos are conditioned to present their cases in front of Amharic-speaking judges, prosecutors, lawyers, and even interpreters. The plaintiffs, judges, lawyers, persecutors, and even the interpreters are part of the system. The legal system works for the interest of Abyssinians.
For my Ph.D. thesis, I collected data regarding how the Ethiopian legal system covertly and overtly discriminates against the Oromo people. One of my informants explained the ways his father lost his ancestral land in the Ethiopian court when he said, “after ten years of fighting in the court, my father was charged for obstructing justice” and lost the rest of his property. There are cases when an Oromo man lost his ancestral lands for calling the supreme court judge a female rather than referring to him using the word that describes a person of authority (Dugassa,2016). The person referred to the judge as a female, not because he disrespected him. He did it because he had not fully mastered the Amharic language. Making grammar mistakes costs ancestral land.
Another informant, who had been forced to pay double taxes because she is an Oromo and unsuccessfully fought the cases in the court, explained how the Ethiopian legal system and Abyssinian elites work together in the form of a metaphor. She explained the metaphor “if you are a visitor of the monster’s village, there you are attacked by a sinister monster, and you cried for help, it is more monsters who will come. They all will attack you. Expecting justice from the Ethiopian legal system is like anticipating monsters to rescue you from another monster.”
Ethiopian criminal laws are purposefully set to maintain structural inequality. During King Haile Selassie’s era, the Oromo people were forced to observe Orthodox Christian holidays[19] (Dugassa, 2015). Many of the Oromo songs of the time articulately describe the social issues. One such song written in prison eloquently described the legal system. The prisoner who wrote the song was jailed for allegedly working on a holiday and stealing the property of an Abyssinian man. In the song, he says: “I am not a man who disrespects a Divine power or a thief who steals someone’s property. I am an innocent man who worked when I had to and retook my stolen property. For working when I had to and taking back my property, they sentenced me to imprisonment.”.
In Ethiopia, violations of individual and collective rights of people and SI unfairly allocates privileges and risks and hinders improvement in human conditions (Dugassa, 2018, 2008, 2006). One of the departments where we can unequivocally see inequality and unfairness is the Ethiopian military. Indeed, the Ethiopian army is one of the institutions that have been used to maintain SI. By all standards, it is the most inequitable institution. For example, from 1991 to 2018, ninety-eight percent of the Ethiopian military generals were Tigray nationals[21].
If we closely look at the structure of the Ethiopian military, we can see the unequal distribution of risks and privileges. Since its formation, the Ethiopian government has not made any viable social reforms. Ethno-national groups conquered in the 1880s struggled to assert their rights to their social, economic, political, cultural, and environmental affairs. The Ethiopian government widened and maintained SI by violently suppressing any political activism and waging undeclared war in all lands of conquered ethnic-national groups. To allocate risks and privileges differently, the government focuses on recruiting the ground forces from non-Abyssinians. SI allows Abyssinians to be promoted to military commander positions quickly. As a result, ground forces are disproportionally represented by Oromos. Departments requiring complex technical skills and paying more, and having relatively fewer risks are mainly left for the Abyssinians.
As mentioned above, from 1974 to 1991, the Ethiopian government conscripted millions of young Oromo men to the war front. These militias were unsalaried[21] and had no compensation or rewards for their services. However, Ethiopian regular armies are salaried, and if they die or are wounded, they will receive compensation. If these salaried soldiers die or are injured, they would cost the government. The Ethiopian government’s strategy to minimize the costs of wars and slash the risks to Abyssinians was through the conscription of unsalaried militias. Those militias were usually sent to military operations considered dangerous.
Researchers have long noted that social and environmental justice are intertwined (Greenbaum et al., 1995). The experience of the Oromo people provides empirically testable evidence of it. The Oromo worldviews about the natural environment are more sustainable. For them, personal health is closely associated with community and ecological health. Caring for the natural environment is seen as part and parcel of caring for individual and community health (Dugassa, 2018b; Dugassa, 2021). However, these views are dishonored by the Orthodox church clergy. They disparagingly refer to the Oromo worldview as one in which nature is worshipped. The church’s opinions about the natural world are formally and informally propagated and made part of the Ethiopian government policy.
Until 1974, Ethiopian environmental policies have been informed by the views of Abyssinian clergy and attitudes toward the Oromo people and culture. These policies are derived from the intent to exploit “the endless natural resources freely.” Such policies have allowed for the degradation of natural environments and widespread chemical and biological pollution. For example, from 1991 to 2018, the TPLF- led Ethiopian government deliberately burned the forests of Oromia, covered water wells, and justified these acts as a way to deny Oromo activists shelter, food, and water (Lemmesa and Perault, 2002). Now the Abiy Ahmed-led government[22] is doing the same. To deny the activists shelter, food, and water and defuse their intent to remove SI, the Ethiopian government has been burning the wild forests of Oromia.
Developments in population health do not just happen because we wish them. They result from profoundly understanding the social processes of health and diseases. This includes recognizing the risk and protective factors that our social realities offer in fostering or hindering community resiliency, promoting health, and setting creative, transformative visions and implementing them. SI hinders the building of institutions, developing leaderships, community resiliency, understanding problems and opportunities, making continuous efforts, enhancing members’ problem-solving skills, providing evidence-based and culturally acceptable social policies. Individuals’ roles in population health development are important; however, their roles are usually limited and short-lived. Institutionalizing our efforts makes them more protracted, creatively envisioned, comprehensive in scope, sustainable, and cost-effective. Enhancing institutional capacities and creating supportive environments requires considerable resources. This necessitates applying the “upstream” public health strategies and removing SI and the development of healthy social conditions. In the Ethiopian case, the removal of SI constitutes either strengthening the federal governing structure or formulating ethnic/national based confederation.
SI hindered the social, economic, political, cultural, and environmental capacity development of the Oromo people. The underdevelopment of those capacities works cumulatively and impedes the development of public health infrastructures, i.e., the means to widen people’s choices in life and develop healthy social policies. When French scientist Louis Pasteur said, “Chance favors only the prepared mind,” he highlighted the idea that individuals and groups could use the opportunities if they are already prepared to see and understand emerging opportunities. Autonomous individuals and societies better develop free-thinking cultures. Free thinking people will build prepared minds- and they better understand complex problems and develop problem-solving skills.
The intent of the Ethiopian government in denying the Oromo people the right to freely determine their social, economic, political, cultural, and environmental affairs for over a century is to widen and maintain SI. Accumulated evidence shows that removing SI is essential so that marginalized groups of people can develop the necessary capacities. If the Oromo people had been freely exercising those rights, they would have better developed those capacities and enhanced their social, economic, political, cultural, and environmental conditions. This makes removing those SIs a prerequisite to the development of public health.
Diseases are much more than unfortunate phenomena. They are the manifestations of deep-seated social problems. Solutions to those social problems go beyond biomedical cocktails. Public health problems require healthy social policies and problem-solving skills – built on knowledge of sciences and arts. To improve those skills, people need to strengthen the essential social environments for learning. The development of public health conditions resembles a learning curve, and the more societies make efforts, the more they improve their circumstances. Learning and problem solving are processes, and people studying as they are engaged in doing (Mercer,1995). The Oromo people are not allowed to identify their needs and advance their interests. For example, if an Oromo person manifests thinking and promoting Oromo interests and welfare, he or she will be character assassinated – labeled “-narrow” or even criminalized. The conditions in which the Oromo people have lived for over a century have hindered them from thinking and advancing their welfare, or continually enhancing their understanding of conditions that put them at risk or protect them. Those social conditions slowed them from developing skills needed to speed up learning and solving their social problems.
Recognizing that individuals and a population’s health status result from multi-layered and complex constructs of social determinants of health necessitates building those multi-layered social conditions. Constructing and synthesizing knowledge in public health and using evidence in policymaking requires meticulous efforts. Generating resources needed in knowledge construction and building those multi-layered social conditions requires developing the health gradients, i.e., people’s social, economic, political, cultural, and environmental capacities. The Oromo people’s experience suggests that those capacities can be built if their social, economic, political, cultural, and environmental rights are respected. This means advancing the rights of people to freely decide on their social, economic, political, cultural, and ecological affairs, as enshrined in the UN charter (ICESCR), is consistent with the core health promotion ideas of creating enabling social conditions and developing healthy social conditions.
I want to apply the analogy of physical exercise and bodybuilding to public health development. The more bodybuilders exercise, the more they develop muscles. Further, the more they choose certain physical activities, the more likely they will develop specific muscles. By the same analogy, the more societies freely exercise and make continuous efforts to understand and solve their social problems, the more they build their capacities. For those reasons, advancing structural equality should be seen as part and parcel of health promotion strategies and “upstream” public health interventions. Promoting an equitable social structure includes popularizing the idea enshrined in the UN Charter, the right of people to freely determine their social, economic, political, cultural, and environmental affairs (See, ICESCR). This includes developing and having access to the social determinants of health. The aspirations for quality of life are shared across cultures. Among autonomous societies, such aspirations fostered the development of those essential public health activities. Conducting knowledge construction, synthesis, and developing policy directions requires building institutions and assembling a team of visionary and knowledgeable leaders (Dugassa,2012). Institutions and leaderships are gradually and progressively developed, and cross-fertilization of health promotion ideas flourish if the people have control over their social, economic, political, cultural, and environmental affairs. An inequitable social structure makes poverty and the daily struggle for survival the norm. This takes away the key ingredients and aspirations that allow people to organize effective institutions and develop strong leadership teams that can transform society and create healthy social conditions (Rowitz, 2001).
Structural inequalities are multipliers of public health problems. This paper closely looked at the relationships between SI and public health underdevelopment in the Oromia regional state of Ethiopia and concluded the following:
First, in Oromia, public health problems, i.e., human rights violations, indignity, poverty, malnutrition, homelessness, scarcity of clean water, and infectious diseases, are not fated to happen by nature. Those unhealthy social conditions are preventable. The underdevelopment of public health conditions in Oromia has resulted from a pathologic social structure, manifested as a) denying people the right to decide on their social, economic, political, cultural, and environmental affairs; b) stripping people of the right to develop leadership and institutions and preventing planned changes; c) compromising employment opportunities and reducing income; d), neglecting and aggravating social problems. Public health conditions are built progressively. Closely looking at SI may help to reorient our thinking and policy directions.
Second, SI has legalized the violations of the social, economic, political, cultural, and environmental rights of the Oromo people. Violations of those rights have consecutively hindered their capacity development; they legalized civic and criminal injustice, the unfair distribution of opportunities and risks, neglected and/or aggravated social problems that are common or severe among the Oromo people.
Third, the European Empire builders’ racist theory and Abyssinian colonial conquest have created SI in Oromia. SI has multiple negative social consequences. Closely looking at SI provides public health researchers and policymakers essential tools to think and act at the “upstream” level.
Inquiring into SI offers theoretical and practical reasons for health promotion, the promulgation of social reforms that advance the collective rights of people, autonomy, and equity in the community.
Fourth, removing SI will create conditions for the Oromo people to freely decide on their social, economic, political, cultural, and environmental affairs. This will help them to foster social transformation, widen their choices, and shape their future. It will enable them to be more resilient, develop problem-solving skills, and promote fair distribution of the social determinants of health. In the Ethiopian case, the removal of SI constitutes guaranteeing autonomy by either strengthening the federal structure or arranging the confederation of different ethno-national groups.
Fifth, fostering social reforms, democratizing society, creating equitable social structures, developing institutions and leadership is essential for public health development. The efforts of the Oromo people to bring social reforms, the removal of SI, and greater equity is part of the “upstream” public health interventions and the desire to make politics “a social medicine.”
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Begna Fufa Dugassa PhD is a researcher with interests in knowledge construction in public health, public health leadership, human rights (individuals-collective), and public health.
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