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Social Problems, 2015, 62, 529549

doi: 10.1093/socpro/spv018
Article

Ecological Losses are Harming Women:


A Structural Analysis of Female HIV
Prevalence and Life Expectancy in Less
Developed Countries
Laura McKinney1 and Kelly Austin2
Tulane University and 2Lehigh University

ABSTRACT
Increased inequality in life expectancies across nations due to the advent of the HIV
pandemic requires rigorous investigation of gender inequalities, as women now disproportionally represent the majority of global HIV cases. While empirical examinations of womens status on HIV prevalence and life expectancy have amassed, one under-explored area
of concern is the inuence of environmental decline. We ll this gap by integrating ecofeminist perspectives to inform our analysis of the direct and indirect effects of ecological losses
on female health outcomes in a structural equation model of 136 less developed nations.
We nd that ecological losses reduce womens longevity via increased HIV rates, hunger,
and diminished health resources. Conclusions point to the importance of ecological conditions and the efcacy of incorporating ecofeminist frameworks to explain global health and
gender inequalities.
K E Y W O R D S : HIV/AIDS; life expectancy; ecofeminism; environment; gender inequality.

The twentieth century brought major worldwide improvements in numerous measures of health, as
economic development and enhanced access to medical and sanitation interventions advanced the
health and well-being of individuals (Soares 2007). Countering such widespread gains, current research charts the reemergence of global inequalities surrounding measures of health, including life expectancy (e.g., Neumayer 2004; Riley 2005). HIV/AIDS is a leading factor contributing to health
declines in poor nations, where over 95 percent of the 33.2 million individuals infected with HIV reside (WHO 2013). The spread of HIV/AIDS has been especially detrimental to women in poor nations and, in fact, represents the leading cause of death among women of reproductive age (WHO
2013).
The number of women infected with HIV has increased dramatically in recent yearsyoung
women in less developed nations are about twice as likely as men to become newly infected with
HIV (WHO 2013). The factors leading to enhanced likelihood of contraction are complex, but often
center on gender-based inequalities that limit their socioeconomic status, access to health resources,
The authors thank the reviewers and editors for their invaluable comments and suggestions. Any errors that remain are entirely their
own. Direct correspondence to: Laura McKinney, Tulane University, 220 Newcomb Hall, New Orleans, LA 70118. E-mail
lauramc@tulane.edu.
C The Author 2015. Published by Oxford University Press on behalf of the Society for the Study of Social Problems.
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McKinney and Austin

1.

We use terms such as ecological losses, ecological destruction, environmental degradation, environmental decline, and biocapacity losses interchangeably throughout the article to refer to reductions in the vitality, quality, and functioning of ecosystems,
broadly defined, that are consequential to subsistence, health, and vulnerability, in general.

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and safe sex practices that would otherwise help prevent infection (Austin and Noble 2014;
Burroway 2012; Heimer 2007; Krishnan et al. 2008). Impoverishment takes an obvious toll on health,
and its effect on the spread of HIV is no exception. The deleterious combination of gender-based
inequalities, poverty, malnutrition, lack of education, and inadequate health resources poses acute
threats to the well-being of women in the less developed world (Krishnan et al. 2008); indeed, these
factors are interconnected dimensions of strife that co-occur and exacerbate one another in ways that
severely compromise the health and longevity of women in poor nations (Shen and Williamson
1999; Williamson and Boehmer 1997). What has been underexplored in the literature is the influence
of environmental factors on womens health outcomes. Although some studies have begun to link select environmental factors to increased HIV transmission (e.g., Hunter, Reid-Heresko, and Dickinson
2011), this is especially relevant to women for a number of reasons.
Womens health is particularly imperiled by ecological losses1 that disrupt flows of the vital resources women are typically charged with providing to the household that are wholly or partially derived from the natural environment (Oglethorpe and Gelman 2008). Indeed, women supply the bulk
of food, water, and other basic necessities for family members; as resource scarcity complicates these
tasks the health and well-being of the family is jeopardized and women themselves become increasingly vulnerable to disease (Barnett and Whiteside 2002; Krishnan et al. 2008; Oglethorpe and
Gelman 2008; Stillwaggon 2006). Environmental declines undoubtedly constrain food production
and malnutrition potentiates susceptibility to many infectious diseases (Scrimshaw 2003; Scrimshaw
and SanGiovanni 1997), including HIV/AIDS (Beisel 1996; Stillwaggon 2006). Additionally, there is
accumulating evidence that high rates of HIV are found in areas with extensive contact with contaminated water. This is particularly harmful to women as they are more likely to encounter contaminated
water in the course of their daily lives and, as a result, experience urogenital inflammation that is a
risk factor for HIV infection (Downs et al. 2011; Kjetland et al. 2006).
Womens needs for such basic provisions are characteristically subsidiary to mens (Santow 1995),
making them disproportionately vulnerable to malnutrition and associated declines in immunity
when food and water are scarce. In some cases, severe hunger may increase the likelihood of risky
sexual behavior and HIV transmission among women who resign to trading sex for needed household
resources (e.g., Heimer 2007; Mojola 2011). Thus, there are many mechanisms that link environmental degradation and womens health; we focus our efforts on uncovering the connections among
the environmental, social, and economic dimensions that are causal determinants of womens health
in less developed locales.
Despite its importance, ecosystem depletion is an under-explored source of death and disease
among women in comparative analyses, which is the gap we fill. To do so, we draw on ecofeminist
perspectives that theorize the deep connection between women and nature that heightens womens
vulnerability to ecological degradation. We wed ecofeminist positions with other macro-comparative
approaches to inform our empirical analysis of the connections among environmental losses, malnutrition, and female HIV prevalence, which directly and indirectly influence each other and the
outcomewomens life expectancy. We predict that the womens health measures are also significantly impacted in direct and indirect ways by additional factors, such as womens status, availability
of health resources, and level of economic development. We begin by discussing the gendered nature
of HIV and associated impacts on longevity, followed by an elaboration of the ecofeminist
approaches that are of key interest. To anticipate, we find support for the basic premise that environmental destruction is a central explanation of declines in health among women, including the spread
of HIV and reductions in life span.

Ecological Losses are Harming Women

531

2.

The status of women is a multidimensional concept that spans legal, economic, political, educational, social, and health realms,
among others (Williamson and Boehmer 1997:306). While acknowledging the conceptual diversity of womens status, we analytically define womens status by educational attainment and two measures of reproductive autonomylow fertility and contraceptive use. We adhere to this operationalization based on its relevance to health outcomes, though we note alternative measures
abound and might usefully be applied in future efforts.

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DEVELOPMENT, HEALTH, AND GENDERED INEQUALITIES


Comparative research emphasizes that premature death and rates of infectious disease are pronounced in poorer nations due to limited economic development, minimal education, poor healthcare services, inadequate provisions for sanitation and water, gender inequalities, and insufficient
access to contraceptives (Austin and McKinney 2012; Austin and Noble 2014; Bates et al. 2004;
Burroway 2010, 2012; Heimer 2007; McIntosh and Thomas 2004; Medalia and Chang 2011;
Neumayer 2004; Riley 2005; Shen and Williamson 1999; Soares 2007). Much research has begun to
focus on the relevance of womens status2 and basic health services in predicting health outcomes, including HIV prevalence and life expectancy (Austin and Noble 2014; Burroway 2012; Medalia and
Chang 2011; Shen and Williamson 1997; 1999; 2001; Wickrama and Lorenz 2002). Indeed, the status of women is an influential aspect to consider as women generally use their increased social power
to address concerns that improve their health (Holvoet 2005; Shen and Williamson 1999; Wickrama
and Lorenz 2002; Williamson and Boehmer 1997).
Globally, women are especially vulnerable to many health problems that lead to early death, including HIV most notably, as well as complications in pregnancy and childbirth (Shen and
Williamson 1999), respiratory infections, malaria, certain cancers, and a number of other conditions.
Theories of gender inequality provide clear insights into such dynamics, as a wide body of literature
highlights the harmful consequences of inequalities in decision making and control of or access to resources for women (e.g., Clark and Peck 2012; Smith 2002; Turmen 2003). In particular, women in
less developed nations face barriers to many educational and health resources, including schools and
contraceptives (Burroway 2012; Heimer 2007; Shen and Williamson 1999; Smith 2002).
Womens participation in schooling is one of the most important cross-national predictors of a
wide variety of health outcomes in less developed nations (Shen and Williamson 1997; 1999; 2001;
Williamson and Boehmer 1997), including HIV prevalence (Burroway 2010; Clark and Peck 2012;
Shircliff and Shandra 2011). Enhanced educational attainment among women reduces gender inequality, as schooling can advance womens economic standing and autonomy, as well as provide substantive knowledge on disease transmission, reproductive concerns, and other areas related to health
and well-being (e.g., Burroway 2010; Shen and Williamson 1997; 1999; 2001; Soares 2007;
Vandemoortele and Delamonica 2002; Wickrama and Lorenz 2002). For instance, educated and financially independent women have more influence in household negotiations, allowing them to exercise greater control over the use of contraceptives (e.g., Smith 2002; Wickrama and Lorenz 2002).
Indeed, enhanced use of fertility-reducing contraceptives directly improves womens health by lessening the chances of maternal death (Shen and Williamson 1999). Moreover, reduced fertility suggests
a declining importance of child-rearing and increased capacity of women to work outside the home
and improve their socioeconomic standing by attending school or engaging in formal employment
(e.g., Heimer 2007; Wickrama and Lorenz 2002).
The strong focus on the status of women as a key predictor of health outcomes fits with critical
analyses that emphasize that non-economic factors improve life expectancy and other measures of
physical well-being more so than prima facie economic growth (e.g., Brady, Kaya, and Beckfield
2007; Franz and FitzRoy 2006; Soares 2007). A growing body of research demonstrates that GDP is
comparatively less influential on health outcomes than factors such as womens education, the availability of health-care personnel, clean water, or sanitation (Brady et al. 2007; Soares 2007), or that
GDP operates indirectly through other measures to influence health (e.g., Noble and Austin 2014).
By extension, we expect womens health to improve when economic development is properly channeled to providing public health resources. Additionally, women must be able to access and utilize

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McKinney and Austin


Economic
Development

Health
Resources

Womens
Status

Female Death
and Disease

Figure 1. Conceptual Mapping of Hypotheses 1 and 2

these resources; womens status likely mediates the relationship between health resources and womens health outcomes. This leads us to consider the following hypotheses (see Figure 1):
(H1) Economic development is linked to improved health resources, including the availability of medical providers and access to water and sanitation.
(H2) Health resources enhance the status of women (measured by school enrollment, low fertility, and
contraceptive use), which, in turn, conditions HIV prevalence and premature death among women.

GENDER, HEALTH, AND THE ENVIRONMENT


Health experts and practitioners are beginning to place greater importance on the role of the environment in perpetuating disease and death among vulnerable populations. The World Health
Organization (WHO) (2006) estimates that roughly one-quarter of all healthy life year losses and
premature mortality, globally, have environmental origins, but caution these are extremely conservative figures. This is particularly problematic for individuals in less developed nations, as sociological
research supports that environmental degradation is amplified in those locales due to the global division of labor that concentrates extractive and highly destructive production processes in peripheral
areas.3 Expectedly, the WHO (2006) confirms that differences across income groups are stark with
individuals in less developed areas losing healthy life years and succumbing to disease at rates 15
times and 120 times greater, respectively, than their developed counterparts. To be sure, the interaction of environmental hazards (e.g., clean water scarcity) with the lack of health-care interventions
(e.g., mass drug administration) in poorer nations compounds these divides.
Quantitative macro-comparative analyses corroborate these claims by showing, for instance, that
water pollution contributes to infant mortality in less developed countries (Jorgenson 2009) and access to clean water and sanitation reduce child mortality in sub-Saharan African (Shandra, Shandra,
and London 2011). Taken together, this research emphasizes that features of the natural and built environment condition health. However, these assessments fail to account for the gender dynamics
that, as we shall show, are important aspects of environmenthuman health linkages. To illustrate,
water pollutants4 are especially critical to women whose traditional household responsibilities increase their reliance on and exposure to water. Similarly, women are more likely to be affected by inadequate domestic health provisions that represent built environment conditions, including water
3.
4.

Though a thorough explanation of these dynamics is beyond the scope of our study, we refer readers to Bunker (1985) and recent review by Rudel, Roberts, and Carmin (2011).
Although water pollution in advanced nations typically emanates from industrial waste, fertilizer use, pesticide applications, and
the like, water pollutants in less developed areas are more accurately characterized as parasitic water contamination and associated infections that result from contact with infested water. To be sure, the bulk of contact with contaminated water springs
from basic domestic activities such as washing clothes, fishing, and gathering water.

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In addition to the social and economic dimensions of development explored above, recent evidence also suggests that ecological factors deserve increased consideration, especially in the context
of health and gender inequalities (see, for example, Hunter et al. 2011; Mojola 2011; Oglethorpe and
Gelman 2008). We now consider environment and health linkages, with a continued emphasis on
the significance of gender in shaping these relationships.

Ecological Losses are Harming Women

533

5.

This is part of the evidence that constitutes what Stillwaggon (2006) refers to as the ecology of poverty that is an overlooked
dimension of disease. Her thesis, substantiated by a meta-analysis of existing studies and her own experiences navigating health

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and sanitation access; in the absence of basic health infrastructure, women evidence higher fertility
rates, less contraceptive use, and less educational attainment (e.g., Heimer 2007; Krishnan et al.
2008; Wickrama and Lorenz 2002).
The links connecting womens status, health, and the environment comprise the theoretical and
empirical focus of this article. Building on prior cross-national research that confirms the harmful effects of pollution and inadequate access to water and sanitation on health outcomes (Jorgenson
2009; Shandra et al. 2011), we incorporate explicit emphasis on the gender dynamics that augment
the adversities experienced by women. We also expand the analytic focus on select environmental factors (e.g., water pollution) to a more encompassing measure of ecological losses that captures multiple dimensions of environmental decline that are of direct relevance to the health and well-being of
women. We draw on ecofeminist theorizations to develop a framework for advancing claims that environmental losses are especially problematic for women, to which we now turn.
Ecofeminist perspectives offer that women are more deeply connected to, affected by, and concerned about the environment than men (Mies and Shiva 1993; Terry 2009; Warren 1990).
Ecofeminist scholars posit that patriarchy and capital accumulation are twin aspects of the current
economic regime that yield numerous consequences for women and the environment; thus women
are deeply connected to nature by virtue of shared structures of domination. Additionally, the traditional household duties and responsibilities accorded to women result in their heightened vulnerability to ecological losses (Mies and Shiva 1993; Mies 1998; Rocheleau, Thomas-Slayter, and Wangari
1996). As one example, the productivity of women in less developed nations relies near exclusively
on subsistence farming (Boserup 1970; Dunaway 2001; Rocheleau et al. 1996); thus declines in soil
fertility and supplies of clean water compromise their ability to provide for themselves and the household (Masanjala 2007).
We focus on women in less developed countries who are theorized to be particularly affected by
environmental degradation due to the division of labor and associated gender norms that position
them as collectors and providers of household resources. As women endeavor to fulfill their household duties in light of resource scarcity, they must travel longer distances over increasingly dangerous
terrain to secure food, fuel, and fiber (Dunaway and Macabuac 2007; Mies 1998; Mies and Shiva
1993). Resource constraints that shift formerly inconsequential tasks, such as walking to a nearby
source to draw water, to hours-long (or even days-long) searches are not only physically strenuous,
thus directly impacting womens health, but also place restrictive demands on womens time that limit
opportunities for educational and economic pursuits that would otherwise improve their status.
Specifically, research shows that women who attend school and engage in cottage industries do so
without reductions in other responsibilities, such as those to the household (King and Hill 1993). In
effect, long searches for resources restrict the time that girls and women can spend on education to
get a job and the ability to work the job itself. Taken together, women disproportionately suffer as
searches for household inputs become onerous, physically intense, and prolonged, the latter of which
can ultimately render unfeasible the educational and economic pursuits that, as treated above, are
powerful avenues for advancing womens status and health.
Environmental declines that disrupt the supply of food and clean water also weaken the physical
capacity of individuals to fight against disease, which is especially consequential to women given their
tendency to eat last (Santow 1995). The loss of fertile croplands, grazing lands, and vital fishing
grounds severely constricts the ability of households to obtain the macro- (e.g., protein and calories)
and micro-nutrients (e.g., iron, zinc, and vitamins) that are critical defenses in resisting disease and
staving off infection (Beisel 1996; Stillwaggon 2006). Quite simply, severely undernourished individuals lack the basic first-line defenses of a healthy immune system.5 Moreover, as supplies of clean
water become increasingly scarce, women are more likely to come into contact with and, ultimately,

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McKinney and Austin

6.

7.

systems in less developed countries, posits that ecological factors are more instrumental in perpetuating HIV infections than behavioral (e.g., sex practices) modes of transmission.
We note, however, that emerging evidence gleaned from Demographic and Health Surveys (DHS) in select African nations
questions this basic logic (see, for example, Fox 2010; Mishra et al. 2007; Parkhurst 2010). These findings point to higher risk of
HIV infection among men and women in the wealthiest income quartiles who are speculated to have the resources to support
multiple partners and a desire to accrue material assets from multiple partners, respectively. We are hopeful future research on
the individual-level determinants of HIV risk explores the environmental factors treated here to discern if they are subject to the
same dynamics across wealth gradients.
This should not suggest that risky sex is the only means for acquiring HIV. Some research suggests that much of womens HIV
risk is in the context of marriage; therefore it is the sexual behavior of their husband that puts them at risk. This is especially the
case when husbands are engaged in migratory labor that often necessitates long absences from home. Importantly, reduced productivity of the land and the political economy of natural resource extraction in general are critical factors pushing rural people
to seek wages in urban areas (Udoh 2013) where HIV prevalence is characteristically higher (Mabala 2006), thus the health of
the environment is implicated yet again as a key determinant of womens health.

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resort to using water that is infested with worms and parasites that compromise overall health by intensifying susceptibility to and progression of life-threatening infections (Stillwaggon 2006). In particular, epidemiological studies confirm that human exposure to water infected by Schistosoma
hematobiumthe predominant cause of female urogenital schistosomiasis (FUS) that manifests in
genital lesionsis a major risk factor among women who have and contract HIV (Downs et al.
2011; Kjetland et al. 2006).
Resource scarcity reduces the prospects for women to generate income from handicrafts and other
cottage industries that rely heavily on natural resource inputs (Dunaway 2001). The additional constriction to earning money posed by ecological decline worsens womens health insofar as they become entrenched in poverty, which is clearly consequential given the general view that poverty is a
major culprit in perpetuating HIV transmission.6 The likelihood of contracting the virus is spiked
among impoverished individuals due to their overall poorer health profiles, greater susceptibility to
disease (particularly when coupled with malnutrition; see, for example, Beisel 1996; Stillwaggon
2006), limited knowledge on preventing transmission (Tladi 2006), and tendency to engage in risky
sexual health behaviors (Dunkle et al. 2004). As resource scarcity diminishes womens options to
earn wages, they are propelled into increasingly precarious positions and often sacrifice their own
health to fend for others who depend on them, as elaborated below.
Ecological declines coupled with the exclusion from socially acceptable means to earn money
provoke some women to resort to prostitution and trading sex for household resources they are
otherwise unable to obtain (e.g., Heimer 2007; Masanjala 2007).7 For instance, the documented fishfor-sex trades in sub-Saharan Africa are indicted as perpetuating HIV transmission among women in
coastal communities who have no other means of feeding themselves or their families (Mojola 2011).
Importantly, risky sex practices are pronounced among women who encounter threats of starvation
(Oyefara 2007), and hunger is often amplified among women in less developed locales (Santow
1995). Ecological losses complicate food access in a variety of direct and indirect ways that collectively perpetuate unsafe sex behaviors among women who face profoundly desperate circumstances
of abject poverty and severe hunger that contribute to their material and physical inability to stave off
infections. Women are, in effect, robbed of safe options for acquiring food for themselves and their
families.
In sum, there are a variety of mechanisms by which environmental declines constitute greater
health risks among women. In this view, resource scarcity bears a wide range of deleterious effects on
the health of women due to traditional gender roles that dictate that women take care of the household, including key tasks of finding clean water and food. The relationship between the environment
and health outcomes is likely cyclical and intergenerational in ways that exacerbate and compound
the strife experienced by each successive generation.
While practitioners and scholars alike have begun to trace certain health deficiencies to select environmental features (Jorgenson 2009; Shandra et al. 2011), other environment-human health linkages
have been omitted entirely from existing assessments. In fact, the WHO (2006) candidly admits that

Ecological Losses are Harming Women


Ecological
Losses

Health
Resources

535

Womens
Status

Hunger

Female Death
and Disease

Figure 2. Conceptual Mapping of Hypotheses 3 through 5

(H3) Ecological losses are tied to declines in health resources that would otherwise boost the status of women.
(H4) Ecological losses contribute to severe hunger that, in turn, leads to greater HIV and associated
declines in life expectancy among women.
(H5) Ecological losses are directly linked to the female HIV burden insofar as women are more likely
to engage in risky sexual behavior to meet household needs.

DATA AND METHODS

Sample
Our sample includes all less developed nations for which data are reported for female life expectancy
in 2012 (World Bank 2013). We restrict out sample to less developed nations, as the predictors of
health, especially HIV, tend to differ across developed and less developed nations.8 As previously
mentioned, issues of poor health, gender inequality, and dependence on local environmental resources are also more pronounced in less developed nations, making it appropriate to focus on poor
nations for the topics explored. Table 1 lists all countries included in the analysis alongside values for
female HIV percent and life expectancy measures used.
Analytic Strategy
To test the theoretical positions outlined above, we construct a structural equation model (SEM).
SEM is particularly useful in this context based on its ability to model direct and indirect effects.
Other features that make it a favorable estimation technique include its ability to create composite indices, model error, and provide model fit statistics that enable the researcher to judge the fit of the
model as a whole to the data provided, and make adjustments based on this information (Bollen
1989). The latter point is particularly helpful in deriving theoretically best-fitted models, given the relatively nascent state of integrating various dimensions from the theories treated above. Another
8.

We follow prior researchers in defining less developed nations as those in the lower three quartiles of the World Bank Income
Classification, which is based on GDP per capita, for the year 2012.

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the disease burden associated with changed, damaged, or depleted ecosystems in general [is] not
quantified (p. 5). It follows, then, that death and disease resulting from ecological decline are likely
far more pervasive than indicated by current authoritative sources. Given the theoretical and practical
impetus for linking ecological destruction to various facets surrounding womens health, we examine
the direct and indirect effects of environmental losses on womens life expectancy via the spread of
HIV, malnutrition, and diminished availability of domestic health resources. In particular, we test the
following (see Figure 2):

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McKinney and Austin

Table 1. Reported Female Life Expectancy and Percent of Women with HIV for Nations
Included in the Analysis
Country

61.35
80.30
72.38
52.56
79.61
77.77
73.73
70.66
76.90
76.56
60.36
67.79
68.86
78.59
46.04
77.05
77.80
56.03
54.96
73.80
55.24
78.20
50.66
51.09
82.27
76.37
77.34
61.83
51.08
59.19
81.84
50.86
80.98
62.40
76.25
78.89
73.09
76.67
53.56
64.11
63.79
72.61
63.75

Female
HIV Percent

.03
1.15
.18
.07
.05
.00
.16
1.73
.69
.15
.07
17.43
.03
.74
1.99
.48
3.18
3.09
1.94
.14
.04
.21
.03
2.00
.12
2.42
.04
1.81
.65
.15
.01
.34
3.33
.47
.05
3.30

Country

Latvia
Lebanon
Lesotho
Liberia
Libya
Lithuania
Macedonia, FYR
Madagascar
Malawi
Malaysia
Maldives
Mali
Mauritania
Mauritius
Mexico
Micronesia, Fed. Sts.
Moldova
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nepal
Nicaragua
Niger
Nigeria
Pakistan
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Romania
Rwanda
Samoa
Sao Tome & Principe
Senegal
Serbia
Seychelles
Sierra Leone
Solomon Islands
Somalia

Female Life
Expectancy

Female
HIV Percent

78.80
81.77
48.46
60.81
76.96
79.30
77.21
65.32
54.23
77.07
78.27
54.03
62.74
76.97
79.36
69.64
72.55
71.21
76.90
72.21
50.48
66.87
66.15
68.68
77.28
57.65
52.02
67.17
80.15
64.32
74.36
76.98
71.90
78.20
64.52
75.94
68.01
64.51
77.30
77.40
45.27
68.69
56.00

.21
.05
15.78
1.00
.03
.07
6.45
.08
.06
.59
.23
.39
.10
.27
.01
.05
6.34
.31
8.61
.15
.07
.37
2.22
.03
.35
.55
.12
.12
.01
.04
1.63

.50
.03
.98
.32
(continued)

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Afghanistan
Albania
Algeria
Angola
Argentina
Armenia
Azerbaijan
Bangladesh
Belarus
Belize
Benin
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Brazil
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Central African Rep.
Chad
Chile
China
Colombia
Comoros
Congo, Dem. Rep.
Congo, Rep.
Costa Rica
Cote dIvoire
Cuba
Djibouti
Dominican Republic
Ecuador
Egypt, Arab Rep.
El Salvador
Equatorial Guinea
Eritrea
Ethiopia
Fiji
Gabon

Female Life
Expectancy

Ecological Losses are Harming Women

537

Table 1. Continued
Country

Female
HIV Percent

59.71
77.54
61.73
75.00
74.94
56.38
55.37
68.52
64.18
75.66
78.70
67.74
72.47
75.43
72.78
83.60
75.71
75.26
73.79
62.12
71.10
84.40
72.30
73.70
68.72

1.18
.06
1.17
.28
.77
1.54
.73
1.36
.32
.02
.15
.07
.03
.06
.73
.09
3.81
.01
.10
.11

Country

South Africa
South Sudan
Sudan
Suriname
Swaziland
Syrian Arab Republic
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tonga
Tunisia
Turkey
Turkmenistan
Uganda
Ukraine
Uruguay
Uzbekistan
Vanuatu
Venezuela, RB
Vietnam
Yemen, Rep.
Zambia
Zimbabwe

Female Life
Expectancy

Female
HIV Percent

57.20
55.09
63.49
73.89
48.16
77.60
70.53
61.31
77.44
68.05
56.64
75.33
76.70
78.09
69.46
59.05
75.88
80.32
71.39
73.16
77.38
80.27
64.08
57.30
56.46

13.00
.81
.42
16.74
.07
3.34
.62
2.15
.02
.00
3.72
.69
.18
.06

.19

9.48

Note: N 136

feature of SEM is its utilization of maximum likelihood estimates (MLE) that calculate pathway coefficients on the basis of all available data points; when cases are missing information on select variables
those cases are dropped from those pathway estimations but retained for others when the data are
available. Thus, SEM allows us to maximize our sample of nations by retaining cases that might be
missing data on one or two variables included in the model.9
9.

Although there were some missing data points, the level of missing data for each measure is relatively low, and some measures
such as female life expectancy, GDP per capita, and fertility rates, had no missing data. Furthermore, there appeared to be no pattern to the missing values that would bias results. Utilizing the strengths of the SEM technique, we use full maximum likelihood
missing value routine. Maximum likelihood missing value estimation is not an imputation procedure. Instead, the likelihood for
the entire sample is created by summing the likelihoods for each case, using whatever information each case has available. This
means that each country contributes the maximum amount of information possible to the estimation (Arbuckle 1996; Enders
and Bandalos 2001). The estimates are consistent and efficient under the condition that the data are missing at random (MAR).
This is an easier condition to meet than missing completely at random (MCAR), which is required for methods of listwise deletion. Analyses that compare missing data methods consistently find that the full maximum likelihood missing value routine is superior to methods of listwise deletion, pairwise deletion, and imputation procedures in terms of parameter estimate bias,
parameter estimate efficiency, convergence failures, and model fit (e.g., Enders and Bandalos 2001). Furthermore, we also conducted the analyses using listwise deletion, as this is the most common strategy used in comparative research, and achieved consistent substantive results (results not presented but available upon request). This demonstrates that the results presented here
are not driven by the missing data method used or the sample size. However, in the listwise-deleted analyses, the sample size was
greatly reduced (N < 50) and such a strategy produces estimates that are statistically consistent but not efficient (Arbuckle 1996;

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Gambia, The
Georgia
Ghana
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
India
Indonesia
Iran, Islamic Rep.
Iraq
Israel
Jamaica
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Rep.
Kosovo
Kyrgyz Republic
Lao PDR

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Expectancy

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Our research design utilizes a time-ordered dependent variable, where the dependent variable is
measured in time after the independent variables. This is a common strategy used in cross-sectional
macro-comparative research in order to help adhere to conditions of causality, where causes must
precede effects in time (e.g., Austin and McKinney 2012; Burroway 2010, 2012; Shircliff and Shandra
2011).10 Also, substantively, it is likely that the effects of environmental decline on womens health
accumulate over time, or carry over across generations. For example, soil depletion from deforestation that inhibits food production may take years to manifest. Thus, we measure biocapacity losses
over a fairly significant period of time (from 1971-2001), and the final outcome of average female life
expectancy is measured later in 2012. We measure HIV in 2009, as there can be several years between
HIV detection and death.11 The predictors of female HIV percent, including hunger, public health resources, and womens status, are measured two years prior in 2007, and GDP is measured in 2005, as
the effects of economic growth on public health resources and womens status may take several
months to be evidenced in cross-national statistics.

Byrne 2009; Enders and Bandalos 2001). We thus prefer to report models that utilize as much information as possible and produce consistent and efficient estimates under the less-restrictive assumption of MAR.
10. Causal assertions and inferences are implicit in SEMs (see, for example, Bollen 1989:40; Pearl 2009:135-8). Future efforts
might apply longitudinal data and companion analytic techniques to confirm causality for the relationships tested here.
11. On average there is around a six to ten year incubation period between HIV contraction and death. However, the average time
from HIV detection to death varies widely, and is often much shorter than this as many people in developing nations do not
get tested for HIV until they are far along in the incubation period. Also, because some people can live with HIV for a considerable amount of time before death, a cross-sectional statistic of prevalence measured at 2009 includes cases that have had HIV
for several years prior (if the HIV measure was an incidence measure, capturing new HIV cases, then a longer time lag between
HIV and life expectancy would be necessary).

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Variables Included in the Analysis


Female life expectancy is our ultimate dependent variable and indicates the number of years a female
newborn can expect to live, on the basis of prevailing mortality trends (World Bank 2013). We focus
on female life expectancy for a few reasons. First, ecofeminist theories emphasize the adversities
posed to women by environmental destruction. As life expectancy represents a common measure of
overall physical quality of life, it follows that female life expectancy is remarkably relevant for testing
such propositions. Second, women (especially young women) in less developed countries are most
vulnerable to contracting HIV, which shortens life span and represents the leading cause of premature death among women of reproductive age (WHO 2013). Third, prior research shows that gender
inequality and HIV prevalence have uniform effects on life expectancy for men and women in less developed locales (see, for example, Medalia and Chang 2011); thus we expect the findings presented
here to evidence similar patterns if other measures of life expectancy (e.g., total or male) were substituted in the analysis. In an alternative specification we considered the ratio of female to male life expectancy as the outcome, which evidenced consistent substantive relationships as those uncovered
here though female HIV prevalence is a comparatively stronger predictor in the model presented
below.
Female HIV represents a key variable in our analysis, given the expected influence on female life
expectancy and the postulation that environmental declines reduce resistance to disease, including
HIV/AIDS (Stillwaggon 2006). Data on the number of female HIV cases come from the UNAIDS
Report on the Global AIDS Epidemic (UNAIDS 2011). Female HIV percent is constructed by dividing the number of HIV-infected women aged 15 to 49 by the total number women aged 15 to 49,
then multiplying that quotient by 100 to form a percent. This variable was log transformed to reduce
the influence of extreme outliers.
Depth of hunger measures the average caloric amount that food-deprived people lack in terms of dietary energy. Each nations food deficit, in kilocalories per person per day, is determined by comparing the average amount of dietary energy that undernourished people get from the foods they eat
with the minimum customary amount of dietary energy needed to maintain body weight and

Ecological Losses are Harming Women

539

12.

13.

Another widely available measure of food insecurity is prevalence of undernourishment, which was tested in alternative models
but failed to reach statistical significance. While this measure is an important dimension of food access, we opt for the intensity
of deprivation among those who lack adequate access to food given the potentiating effects of starvation or extreme hunger on
morbidity and mortality (Beisel 1996; Stillwaggon 2006). We refer readers to Food and Agriculture Organization (FAO)
(2010) for data calculation details.
Although some studies use health expenditures to capture health resources or services, health spending estimates are influenced
by the use of expensive medical equipment, high costs of intensive care for older individuals with chronic conditions, and a variety of other factors. Trained health-care workers and access to sanitation and water are favored measures of the health resources
that are central to preventing disease and extending life expectancy.

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undertake light activity (World Bank 2013). We include this variable to assess the hypothesis that
biocapacity losses punctuate hunger, which is especially consequential to womens health. We use
this measure rather than other indicators of food insecurity,12 precisely because the severity of hunger
and starvation most closely captures the dire circumstances that increase susceptibility to disease
(Beisel 1996; Stillwaggon 2006) and the likelihood of engaging in risky transactional sex behaviors
(Mojala 2011; Oyefara 2007).
Prior analyses confirm that multiple aspects of womens status are central to improving womens
health, including reducing HIV and increasing life expectancy (e.g., Austin and Noble 2014; Brady
et al. 2007; Medalia and Chang 2011; Shircliff and Shandra 2011; Wickrama and Lorenz 2002). We
include three commonly used indicators to estimate the effects of womens status: fertility rate, contraceptive use, and female schooling, which numerous studies demonstrate are among the most important predictors of general and female health outcomes (e.g., Brady et al. 2007; Shen and
Williamson 1997, 1999, 2001; Wickrama and Lorenz 2002; Williamson and Boehmer 1997). Fertility
rate indicates the number of children an average woman would have if current age-specific fertility
rates remained constant during her reproductive years (World Bank 2013). In this analysis, we reverse code this variable to construct a measure of low fertility rate, so that higher values indicate relative improvements in the status of women. We also include the percent of women using contraceptives
to represent the percentage of women aged 15 to 49 who are practicing, or whose sexual partners are
practicing, any form of contraception (World Bank 2013). Although only some forms of contraceptives protect against HIV transmission, use of any contraceptive method suggests increased power of
women in negotiating their reproductive rights, another crucial factor of womens status. Lastly, we
include female secondary school enrollment to measure gross enrollment ratio, where the ratio of total
enrollment for females, regardless of age, is divided by the population of the age group that officially
corresponds to secondary level education (World Bank 2013). Female participation in schooling is
linked to myriad improvements in the status of women, as educated women are better positioned to
earn money, access health-care resources, and evidence greater autonomy (e.g., Burroway 2010,
2012).
General domestic health resources represent important control variables in the analysis. We include number of health providers to estimate the number of doctors, nurses, and midwives per 1,000
people, which includes generalist and specialist medical personnel (World Bank 2013). Access to sanitation and clean water are additional public health factors that can also be considered features of the
built environment, thus having central relevance to biocapacity losses and health.13 Access to improved
sanitation indicates the percent of the population with at least adequate access to disposal facilities
that can effectively prevent human, animal, and insect contact with excreta, including flush systems
(to piped sewer system, septic tank, or pit latrine), ventilated improved pit latrines, pit latrines with
slab, or composting toilets (World Bank 2013). Access to clean water designates the percentage of the
population using an improved drinking water source ranging from piped water located inside the
users dwelling, plot, or yard to other improved water sources, such as public taps or standpipes, tube
wells, or boreholes, protected dug wells, protected springs, and rainwater collection.
We include GDP per capita as a measure of economic development, which is an essential control
in cross-national analyses. We expect GDP per capita to influence many key variables, directly and

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ANALYSIS AND DISCUSSION OF RESULTS


Table 2 displays the correlation matrix and descriptive statistics for the variables used in the analyses;
all bivariate correlations are significant at the p < .05 level or better. The magnitude of the relationships among the variables demonstrates that many of the predictor variables are highly correlated,
such as the indicators of womens status (fertility, contraceptives, female schooling) and health resources (health-care providers, sanitation, clean water). This further warrants the use of SEM given
its superior handling of intercorrelated independent variables through the creation of latent constructs and direct and indirect pathways that circumvent the tendency to bias coefficient estimates
(e.g., Bollen 1989; Byrne 2009).16
A preliminary step was to validate empirically whether health resources and womens status represent distinguishable components. Drawing on prior scholarship, we expect these are distinct as the
former concerns health provision availability across all individuals, while womens status indicators
capture womens access to and benefit from use of such resources. To test this, we performed a confirmatory factor analysis with two separate factors: health resources (indicated by health-care providers and access to sanitation and clean water) and womens status (specified by low fertility,
contraceptive use, and female schooling) and analyzed the overall and component measures of fit.
We compared this to an alternative model where all six indicators loaded on a single factor.17 By empirical standards, we find evidence at both the component and overall model levels to support our
14.

15.

16.

17.

This time period is chosen based on the generally accepted view that time lags of several decades (Wackernagel et al.
2004:271) exist between the ecological changes and social impacts that constitute our analytic focus. We derive this value by dividing biocapacity in 1971 by the change in biocapacity from 1971-2001: (T2-T1)/T1. We then multiplied by negative one
(*-1) to ease interpretation of results such that larger values indicate greater losses.
We tested additional measures such as Exports as a Percent of GDP and Multinational Corporate Penetration. None of these
indicators significantly impacted female HIV or life expectancy, thus they were removed from the model and are not included
as a theme of the article.
Before conducting the SEM analysis, we performed basic regression diagnostics (e.g., residual plots, Breuch-Pagan Test, White
Test, Cooks D) using Stata 13 of sets of regression models predicting both female HIV and life expectancy. No problems with
influential cases or heteroscedasticity were evidenced. While endogeneity is also a concern, we rely on theories and prior evidence to include the predictors most relevant to female health outcomes identified in the literature.
Results available upon request.

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indirectly, in line with the theoretically derived hypotheses treated above. GDP per capita is the total
market value of all final goods and services produced in a country in a given year, equal to total consumer, investment, and government spending, divided by the midyear population. It is converted into
current international dollars using purchasing power parity (PPP) rates, which provides a standard
measure allowing for cross-country comparisons of real price levels (World Bank 2013). We performed a log transformation of this variable to reduce the influence of extreme outliers.
Biocapacity loss is a key independent variable in this analysis, measured as the percent change in
domestic ecological resources for the years 1971-2001.14 This variable, taken from the Global
Footprint Network (2010), quantifies reductions in the amount of biologically productive resources
available to individuals in a nation and is comprised of stocks of grazing land, cropland, forestland,
and fishing grounds. While prior scholarship employs select measures of natural capital losses (e.g.,
deforestation used by Hunter et al. 2011), we prefer this measure given the comprehensive assessment of diverse indicators of environmental destruction that closely depicts the hypotheses we test.
Another point of departure is that our measure is a per capita measure, which provides a meaningful
basis for comparison that illuminates the severity of ecological crises and resource declines as distributed across the population. Biocapacity loss is taken as an exogenous variable, co-varied with our
other exogenous term, and specified as indirectly influencing the life span of women via effects on domestic health resources, hunger, and female HIV percent. Expectations based on the literature reviewed above are that losses diminish domestic health resources, worsen hunger, and exacerbate HIV
prevalence among women, which bring associated declines in life expectancy.15

Ecological Losses are Harming Women

541

Table 2. Correlation Matrix and Univariate Statistics


1.

2.

3.

4.

5.

6.

1. Female life expectancy


2. Female HIV percent (ln)
3. Depth of hunger
4. Fertility rate (reversed)
5. Contraceptive use
6. Female secondary schooling
7. Health service providers
8. Access to improved sanitation
9. Access to clean water
10. GDP per capita (ln)
11. Biocapacity losses

1.000
.647
.603
.801
.711
.745
.594
.768
.698
.672
.469

Mean
Standard deviation
Maximum
Minimum

68.89 5.56 112.48 3.49 44.51 65.62


9.69
2.01 108.04 1.61 22.96 29.60
84.40 1.16 640.00 1.21 96.00 112.55
45.27 10.50
.00 7.59 7.60
4.63

1.000
.521
.522
.378
.440
.341
.510
.455
.331
.550

7.

8.

9.

10.

11.

1.000
.564 1.000
.348 .762 1.000
.544 .831 .725 1.000
.607 .598 .583
.746 1.000
.536 .762 .672
.823 .674 1.000
.552 .777 .654
.787 .612
.771 1.000
.519 .760 .721
.822 .676
.781
.743 1.000
.479 .522 .391 .390 .434 .398 .460 .305 1.000
.44
.15
.63
.06

predictions that the two-factor model is superior, which resonates with our substantive and theoretical interpretations of prior development and gender stratification literatures.
Figure 3 presents the final SEM results of female life expectancy as directly and indirectly conditioned by the various environmental, social, and economic factors outlined above. We derive our final
SEM through an iterative process that begins by testing all theoretically and substantively informed
paths proceeded by successive steps of eliminating non-significant relationship(s) and model reestimation to achieve maximal parsimony and optimize model fit (based on statistical significance of
coefficients and fit statistics), as is standard practice in the SEM tradition (Byrne 2009). To establish
that the inclusion of non-significant paths did not substantively change the results presented in the
parsimonious model (Figure 3), we append Figure A1, which provides a more fully specified model
for inspection. A close comparison of the model fit statistics, treated below, clearly suggests that the
parsimonious model is superior, and thus we focus our discussion of results on Figure 3.
Before interpreting our findings, we note the model fit statistics indicate an excellent fit of the
model to the data. Specifically, in accordance with empirical standards, the chi-square test statistic is
non-significant (v2 46.61; df 38; p .159); the values of the incremental fit index (.992),
Tucker-Lewis index (.985), and Confirmatory Fit index (.991) all exceed .90; and the root mean
squared error of approximation (RMSEA) value (.041) is below the suggested threshold of .05
(Bollen 1989; Byrne 2009). Together, the overall fit indices demonstrate that the model presented
has excellent fit to the data and permit interpretation of the pathway coefficients, which appear as
standardized regression coefficients and are all statistically significant at the .05 level or better.
The results presented in Figure 3 demonstrate that biocapacity loss represents an important underlying factor that contributes both directly and indirectly to health declines, especially among
women, in less developed nations. Specifically, we find that biocapacity losses are directly associated
with reductions in the availability of domestic health resources (.29), such as sanitation and clean
water, intensification of hunger (.21), and increases in HIV rates among women (.26). We also find
that the depth of hunger increases the level of female HIV (.26) across less developed nations. These
results suggest that the effects of resource declines on women operate in ways that fully support ecofeminist positions that emphasize that women bear the brunt of environmental declines; we extend
this view to include the increased likelihood of contracting life-threatening infections and associated
reductions in life expectancy.

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1.26 60.99 81.09 8.22


1.29 30.01 17.13 1.03
4.68 100.00 100.00 10.17
.02
9.10 28.50 5.80

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McKinney and Austin

In addition to biocapacity losses and the depth of hunger, womens status represents a principal
predictor of female HIV rates and life expectancy. Lowered fertility, increased use of contraceptives,
and secondary female education enrollment are tied to reduced female HIV prevalence (.24) and
longer female life expectancy (.72) across less developed nations. As expected, the percent of women
with HIV is associated with reductions in female life expectancy across nations (.26). Overall, these
findings confirm the key hypotheses under investigation by demonstrating the importance of environmental decline, intense hunger, and the status of women in explaining cross-national variation in female HIV rates and life expectancy.
Consistent with our substantive interpretations of prior literature, we also find that health resources are strongly associated with womens status (.97). Yet, as previously mentioned, these represent distinct factors; this suggests that while improved health resources tend to confer advances in
womens status, health resources only improve female health outcomes insofar as women are able to
utilize them. Put differently, health resources evidence no direct effects on female HIV percent or life
expectancy (see Table 2), but indirectly condition womens health via improvements to basic indicators of womens status. Health resources are also associated with declines in the depth of hunger
(.52), suggesting that individuals in countries with better health services experience less starvation.
In contrast to the harmful role of biocapacity losses on health resources, the results confirm that
GDP per capita increases health provisions (.79), where nations with higher levels of economic development evidence greater access to health-care providers, sanitation, and clean water.
It is important to note that GDP per capita did not have any other direct relationships to alternative predictors in the model. In many ways, this supports current research emphasizing the relative
importance of social measures in predicting health outcomes, rather than solely focusing on economic
determinants (e.g., Austin and Noble 2014; Brady et al. 2007; Soares 2007). Additionally, this finding
suggests that economic development only benefits womens health when channeled to improving

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Figure 3. SEM Predicting Female Life Expectancy in Less Developed Nations

Ecological Losses are Harming Women

543

health provisions, and subsequently womens access to them. Equally as notable is the insignificant effect of GDP per capita on depth of hunger when the pathway is included in the model, though the
coefficient came very close to meeting traditional thresholds of statistical significance. In fact, inclusion of this pathway worsened model fit, though all other significant coefficients and substantive interpretations remained. Thus, we extend the logic above to apply to the determinants of hunger as
well, in emphasizing the critical role of health provisions (themselves influenced by ecological conditions) in improving a wide range of health outcomes.

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CONCLUSIONS AND IMPLICATIONS


The analysis presented above imparts a number of theoretical and methodological insights for
approaches to gender, ecology, and health in the less developed world. Primary to this endeavor is expanding our understanding of the factors that contribute to the health, well-being, and longevity of
women in poor nations. The theories and empirics presented above inform our central conclusion
that environmental losses are strongly associated with womens health, in direct and indirect ways.
This implies that developmental and epidemiological approaches to improving womens health may
benefit from incorporating environmental dimensions as a key area of concern. Concomitantly, if we
are to gain footing in this direction, it is equally as critical that companion methodologies are employed that enable researchers to model the complex theoretical hypothesesthat include direct and
indirect effectsthey purport to test. In what follows, we elaborate on these conclusions, associated
implications, and avenues for future research.
Theoretically, we find robust support for ecofeminist propositions and extend the empirical basis
of this framework to confirm that womens health is deeply linked to ecological destruction. In doing
so, our results fill an important gap in the ecofeminist literature that is generally lacking in macrocomparative quantitative assessments (for exceptions, see Ergas and York 2012; Norgaard and York
2005; Nugent and Shandra 2009), particularly those that uncover the underlying mechanisms that
connect gender to environmental conditions (Ergas and York 2012:966). The implications include
the efficacy of incorporating ecofeminist frameworks into global perspectives on health, gender inequality, and the environment; in fact, our results suggest that failing to recognize the interconnected
nature of these dimensions could lead to severely underspecified models. Though we focus solely on
less developed countries, we advocate future research incorporate ecofeminist frameworks to test key
propositions across developmental contexts.
We also conclude that ecological losses are closely linked to hunger and health provisions in poor
nations, which are subsequently tied to female HIV and reductions in life expectancy among women.
Our analysis enables greater specification of the nexus of linkages among environmental degradation,
malnutrition, health resources, and health outcomes across nations. While the negative effect of environmental decline on subsistence is theorized (see, for example, Masanjala 2007; Oglethorpe and
Gelman 2008), we provide empirical evidence of such dynamics in poor nations that are especially
consequential for women. The ways in which ecological losses condition public health resources is a
similarly theorized and practical position (see, for example, WHO 2006), but one that might benefit
from greater exploration. Our findings suggest that not only are aspects of the built environment,
such as water and sanitation, linked to environmental decline, but that the presence of medical
professionals also suffers as a result. We speculate that doctors and physicians might find resourcedamaged locales particularly unhospitable and this could be an important factor in inducing a brain
drain phenomenon in which trained medical personnel avoid such locations, though in-depth research is needed to explore those connections. Thus, we advocate further research be conducted in
these settings to strengthen our understanding of how environmental declines confer losses to domestic health resources that go beyond particular aspects of the built environment.
Our findings give support to frameworks that incorporate non-economic factors alongside traditional economic considerations in explaining gender-based health inequalities across nations. The use
of an integrative modeling strategy illustrates that some commonly assumed relationships involving

544

McKinney and Austin

18.

Data on gender equality across nations recently developed and released by the United Nations could be helpful in this regard.

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GDP per capita and health resources are not direct in their impacts on womens health. Rather, we
find that womens status and health resources themselves mediate many of the economic and noneconomic influences on female HIV and life expectancy. This finding suggests that economic growth
needs to be carefully channeled to improving health resources and that womens access to those resources is fundamental to cultivating companion advances in their health conditions. We modestly infer that practitioners and policy makers seeking to address current health crises in poor nations may
begin to consider holistic approaches that account for the synergies among social, economic, and ecological dimensions. The analysis presented here provides preliminary empirical support for the myriad ways in which social, economic, and environmental conditions directly and indirectly influence
womens health, and we advocate future research employ similar tactics to scrutinize applicability to
other health dynamics across populations of interest.
Methodologically, our results underscore the importance of using statistical techniques that permit
the estimation of complex hypotheses, such as those presented here, that specify a suite of factors
that influence each other and outcomes of interest in direct and indirect ways. SEM is one such possibility for honing the precision of model specification and associated results, which are critical considerations for moving a discipline forward. SEM is also particularly useful as a theory generator; in the
present context this is especially advantageous given the relatively nascent state of theorization and
companion empirics that connect the status of women to environmental dimensions. We strongly
recommend greater incorporation of methodological approaches that reflect the ways in which concurrent (environmental, economic, social) systems interact to shape the various contours of global
inequality.
Our analysis, like all others, is subject to certain limitations. The data available to researchers are
often deficient in many ways as they reflect the focal needs of international organizations that spearhead international data collection efforts. We feel further empirical precision would be beneficial to
analyze the linkages that connect gender inequality and the environment. For example, a breakdown
along gender lines for the depth of hunger variable we employ represents one such refinement; that
is, a measure of the depth of hunger among women would be preferable to the indicator used here,
though we are unaware of existing data in this regard. Similarly, income inequality by gender represents another useful variable for inclusion that is currently unavailable. Should those data become
available, we advocate for further analytic scrutiny of those measures. Additionally, endogeniety is a
concern in any analysis. We endeavor to limit potential bias by carefully constructing theoretically
grounded models that include a host of economic and social factors identified to be important explanations of womens health outcomes, in addition to the environmental factors that are our chief focus.
While not exhaustive in including the universe of potential influences, we hope our findings lay a
foundation for future work in the area.
To this end, we offer a few additional avenues that warrant further exploration. While our primary
analytic focus rests on the effects of environmental degradation on womens social and health status,
there are other possibilities that should also be examined. For example, the logic presented above
that elaborates the ways in which ecological losses are associated with declines in womens status and
health that could, in principle, be extended to female political, legal, and economic achievements.
With respect to political realms, for instance, case studies demonstrate how womens representation
in political structures promotes policies that are critical to rectifying issues of gender inequality, including changes that address gender-based violence and extend landholding rights to women18 (see
Burnet 2011; Devlin and Elgie 2008); we encourage future research to discern if policies enacted also
improve womens health. Beyond legislation, ethnographic research in Rwanda (the world leader in
proportion of parliament seats held by women) has uncovered the additional benefits to women perceived as emanating from their greater political representation, such as the respect of their kin and

Ecological Losses are Harming Women

545

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community, public inclusion, autonomy, and educational access (Burnet 2011). It follows that the
positive outcomes associated with political representation might also improve womens health
through legislative and indirect channels, which is a possibility that warrants rigorous investigation.
We conclude that efforts to stem the spread of HIV/AIDS in less developed locales may benefit
from focusing on women and addressing the root causes of their increased vulnerability to death and
disease, which we have shown to be closely linked to environmental conditions. Womens status is
also deeply tied to reductions in HIV and longer life expectancy for women; thus gains in womens
status may offset some of the harmful aspects of environmental decline. Future inquiries might fruitfully examine the potential relationships between womens status and treatment of the environment,
as the theories and analysis presented suggest improvements in one area has positive, ripple effects
on the other.
Focusing on the importance of women to address the HIV pandemic is a practical stance, given
that women are more efficient transmitters of the virus via sexual intercourse and mother-to-child
transmission (e.g., Heimer 2007); thus, failing to orient discussions around rates of infection among
women omits prevailing pathways of transmission. Additionally, debilitating disease among women
that renders them unable to perform traditional caretaking roles brings wider losses incurred by the
household and community. Children who are orphaned as a result of losing their mother to HIV/
AIDS are more likely to contract the disease themselves (if they are not infected at birth) due to the
abject poverty they are born into that severely limits their options for obtaining provisions to meet
their basic needs (Masanjala 2007; Oglethorpe and Gelman 2008; Stillwaggon 2006; Tladi 2006).
Tragically, many are forced into prostitution and transactional sex practices as a result, which further
exacerbate possibilities for infection (Oglethorpe and Gelman 2008). Our findings suggest that environmental destruction is closely linked to female HIV and life expectancy, thus curbing ecological declines might be advantageous to promoting the sustainability of nations and the people in them.
As an encouraging trend, the administration of anti-retroviral therapies (ARTs) is increasing globally and has recently been scaled up in Africa, though gaps in access to ARTs persist. ARTs are extremely beneficial to HIV-infected people, as they have the potential to prevent mother-to-child
transmission and transmission between partners, while also lengthening lifespan and boosting the
health of those infected with HIV. Therefore, as ART coverage continues to improve, it is likely that
the profound effects of HIV on measures such as life expectancy will lessen. However, the effects of
ART expansion on longevity or quality of life are likely to be extremely unevenfor example, in
North Africa only 11 percent of adults living with HIV are receiving ARTs with the global average in
ART coverage across less-developed nations estimated at 34 percent (UNAIDS 2013:4). The gaps
for HIV-positive children are even worse with only 6 percent of those residing in North Africa receiving ARTs, and an average of 28 percent of pediatric HIV cases across Africa receiving the ART medicines they need (UNAIDS 2013). A number of logistical and even biological hurdles to ART
solutions remain, ranging from issues of treatment eligibility, service gaps, and costs to medicinal regime adherence and the evolution of drug resistant strains (DART Trial Team 2010; Stevens, Kaye,
and Corrah 2004). Moreover, all of the treatment scenarios assume every person has been tested and
is aware of their current status, which is not the case for the majority of individuals in poor nations
(UNAIDS 2013). Quite simply, it looks unfavorable at the present moment that ART drugs will be
able to keep up with the continued spread of HIV. In addition to scaling up access to ART treatments, we offer that taking action to preserve the state of the environment is a pathway with potential
to address the root causes of HIV infection.
Notably, in the current context of global climate change the dynamics treated here are and will
continue to be of the utmost importance. To the degree that climate change creates environments in
which populations must adjust to long-term climatic changes (e.g., shorter growing seasons, higher
mean temperatures) and erratic weather events (e.g., more frequent and severe floods and droughts),
we can expect that resource scarcity, declines in productivity, and shifts in production relations are
likely to occur with adverse effects on the health and well-being of individuals. As we have shown,

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environmental losses are especially harmful to women and thus should be taken as a foremost concern for climate justice and gender equality advocates.
APPENDIX

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