Towards parity democracy
Authors: Carlos Alvarez-Dardet, Maria Teresa Ruiz-Cantero
Journal: The Lancet Global Health (2016)

Although no systematic causal review has yet been done, the evidence of a relation between democracy and health is increasingly convincing.1Pickett KE Wilkinson RG Income inequality and health: a causal review.Soc Sci Med. 2015; 128: 316-326Crossref PubMed Scopus (890) Google Scholar In The Lancet Global Health, Hannah Pieters and colleagues2Pieters H Curzi D Olper A Swinnen J Effect of democratic reforms on child mortality: a synthetic control analysis.Lancet Global Health. 2016; (published online Aug 1.)http://dx.doi.org/10.1016/S2214-109X(16)30104-8Google Scholar report a an innovatively designed study and a novel application of the synthetic control method to investigate the issue of democracy and infant mortality. They investigated whether political transition into democracy that had lasted for at least 10 years affected child mortality, as a proxy for health. Among 24 countries with good counterfactuals, changes in 15 were not significant but nine (38%) showed significant reductions in infant mortality after democratisation. Among these nine countries the average reduction was 13%. Interestingly, the effect increased over time, suggesting that there is an induction period for change while services and organisation are improved. Of note was that the benefits of democratisation increased with increasing child mortality before political change. The design innovation came from the units of observation, which in this case were countries that had transitioned from regimes with restricted freedom to democracies. Thus by studying ‘incident’ cases (change in status), the authors avoided selection bias and temporal ambiguity, which strengthens the case for the causal relation between democracy and health. These issues were seen in previous studies (including our own)3Franco É Élvarez-Dardet C Ruiz MT Effect of democracy on health: ecological study.BMJ. 2004; 329: 1421Crossref PubMed Scopus (181) Google Scholar that have used ‘prevalent’ cases (current regime) and one study4Mackenbach JP Hu Y Looman CW Democratization and life expectancy in Europe, 1960–2008.Soc Sci Med. 2013; 93: 166-175Crossref PubMed Scopus (69) Google Scholar that did a cross-sectional time-series analysis to compare situations after versus before democratisation. If democracy is good for health, it must be questioned whether deepening democracy would improve health further. We believe there is clear room for improvement in democracy and health by taking into account the distribution of power in populations. In most populations, men have more power than women. This gender order means that men generally enjoy patriarchal dividends in wages (division of labour), power (political and corporate), and cathexis (investment of mental or emotional energy).5Connell RW Gender and power. Stanford University Press, Stanford, CA1987Google Scholar In this arena, the notion of empowerment is necessary because it involves bringing to the foreground the value of autonomy and embracing the ultimate goal of gender equality policies. Thus, an empowered individual is recognised not so much as being entitled to wellbeing, but rather as an agent with his or her own skills, values, judgements, and priorities that he or she may use to achieve wellbeing. Empowerment also involves accepting the need for public policies aimed at building political communities where all citizens participate in designing the social framework and fabric.6Sen A The idea of justice. Belknap Press, Cambridge, MA2009Crossref Google Scholar Of note, gender equity might continue despite the economic development of a society. Studies by Nussbaum7Nussbaum M Women and human development. Cambridge University Press, Cambridge2000Crossref Google Scholar and Sen6Sen A The idea of justice. Belknap Press, Cambridge, MA2009Crossref Google Scholar have shown no direct relation between wealth and equity. Hence, some countries with high wealth, such as Saudi Arabia, also a have high degree of gender inequity, whereas others with low wealth, such as Lithuania, have taken substantial steps towards achieving gender equity.8Fernández-Sáez J Ruiz-Cantero MT Guijarro-Garví M et al.Looking twice at the gender equity index for public health impact.BMC Public Health. 2013; 13: 659Crossref PubMed Scopus (13) Google Scholar If half of the population is disadvantaged, a worldwide strong political move to parity is needed. The UN declared that 1976–85 was the decade of the woman. This move was crucial to put women's rights on the global agenda. Similarly, the Athens declaration of women in power in 1992 made an explicit call for greater participation of women in politics. Clearly, however, the advances in these areas remain small 40 years later. What can we do as health professionals to move this situation forward? We lack information on actions taken to change communities to lessen gender gaps. To find out such information the main tool will be participatory action research, which is a mixture of the action research strongly developed by psychologists, such as Lewin,9Lewin K Action research and minority problems.J Soc Issues. 1946; 2–4: 34-46Crossref Scopus (2843) Google Scholar and participatory research initiated by Freire in Pedagogy of the Oppressed.10Freire P Pedagogy of the oppressed. Penguin, Harmondsworth1972Google Scholar Additionally, models of good practice need to be created and spread. It is from this position that Freire derives his dictum that reflection without action is sheer verbalism or armchair revolution, and that action without reflection is pure activism, or action for action's sake. In our opinion, this idea describes the approach to gender issues so far. Action is urgently needed, but in the right directions, which, surely, will further lower infant mortality. We declare no competing interests. Effect of democratic reforms on child mortality: a synthetic control analysisOur results are consistent with the interpretation that democratic reforms have the greatest effects when child mortality is a direct concern for a large part of the population. Future research could focus on identifying the precise mechanism through which the effects emerge. Full-Text PDF Open Access