Good news for democracy
Authors: Helen Epstein
Journal: The Lancet (2019)

Do we really need democracy? Clashes between populist political movements and liberal institutions have raised urgent questions about how human beings should be governed. According to an Article by Thomas J Bollyky and colleagues1Bollyky TJ Templin T Cohen M et al.The relationships between democratic experience, adult health, and cause-specific mortality in 170 countries between 1980 and 2016: an observational analysis.Lancet. 2019; (published online March 13.)http://dx.doi.org/10.1016/S0140-6736(19)30235-1Summary Full Text Full Text PDF PubMed Scopus (80) Google Scholar in The Lancet, democracy is good for public health. Using cause-specific mortality and HIV-free life expectancy estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016, and information on regime type from the Varieties of Democracy (V-Dem) project, Bollyky and colleagues analysed the association between democratisation and population health in 170 countries between 1980 and 2016. They found that adult HIV-free life expectancy improved faster in developing countries that transitioned to democracy in the past half-century. The quality of democratic life, particularly free and fair elections, accounts for 22% of the variance in cardiovascular disease over time within countries, 18% of the variance in traffic injuries, 17% of the variance in tuberculosis, 10% of the variance in cancer, and a smaller fraction for other, mainly non-communicable, diseases included in the study. This is far more than the gross domestic product (GDP), which accounted for only 11% of the variance in cardiovascular diseases, and only 6% of the variance in cancers, for example. The quality of democracy appears not to be associated with increases in GDP per capita, but is associated with declines in mortality from cardiovascular disease and increases in government health spending. The integrity of these findings depends on the data sources. The GBD 2016 and V-Dem databases both use models with various assumptions, and the mismeasurement of democracy, in particular, could bias the results. More open, democratic countries allow more complaints about human rights abuses, which could make these countries seem more autocratic than they are. Staunch US military allies might receive less human rights scrutiny2Qian N Yanagizawa-Drott D The strategic determinants of US human rights reporting: evidence from the Cold War.JEEA. 2009; 7: 446-457Google Scholar and more development aid. The aid would be expected to improve overall health, and the reduced scrutiny could generate artificially rosy democracy measures. The effect of these various biases would weaken the observed effect of democratic performance on health. Thus, the relationships measured by Bollyky and colleagues might be even stronger. Bollyky and colleagues maintain that democracy probably functions like Adam Smith's invisible hand, which creates equilibrium between supply and demand.3Smith A An inquiry into the nature and causes of the wealth of nations. W Strahan & T Cadell, London1776Crossref Google Scholar But where the invisible hand regulates markets for the things we want, the invisible hands of scandal, media exposure, elections, and reform help to regulate the health systems—both public and private—that deliver the care we need. Historians have shown how expansion of the franchise and civil rights to all white men, and eventually to women and people of colour, played a major role in improving health in the UK and the USA.4Szreter S The population health approach in historical perspective.Am J Public Health. 2003; 93: 421-431Crossref PubMed Scopus (86) Google Scholar, 5Almond D Chay KY Greenston M Civil rights, the war on poverty, and black-white convergence in infant mortality in the rural south and Mississippi. MIT Department of Economics Working Paper No. 07-04.https://ssrn.com/abstract=961021Date: Dec 31, 2006Date accessed: February 12, 2019Google Scholar Bollyky and colleagues' new study suggests the same applies globally. These findings extend Bollyky's 2018 historical survey,6Bollyky TJ Plagues and the paradox of progress: why the world is getting healthier in worrisome ways. MIT Press, Cambridge, MA2018Crossref Google Scholar which describes how, during the past century and a half, mortality in high-income countries declined and health systems improved in parallel with rising incomes and better living conditions, in what economist Angus Deaton has called the “Great Escape” from poverty and illness.7Deaton A The great escape: health, wealth and the origins of inequality. Princeton University Press, Princeton, NJ2015Google Scholar Beginning in the 1980s, the international donor community, confronted with stubbornly high child death rates in poor regions of Africa, Asia, and Latin America, decided to take a shortcut, investing in magic bullets such as vaccines, antiretrovirals, and bednets that could be distributed without a well functioning health-care system, and even in war zones.8Fifield A A mighty purpose. How Jim Grant sold the world on saving its children. Other Press, New York2015Google Scholar These programmes saved millions of lives, but failed to launch the anticipated virtuous cycle of development, poverty reduction, and improved health systems. Many African countries remain deeply impoverished, and although child mortality has plummeted, weak health systems remain ill-equipped to address soaring numbers of deaths and disability from heart disease, cancer, and other non-communicable diseases.9Nyaaba GN Stronks K de-Graft Aikins A Kengne AP Agyemang C Tracing Africa's progress towards implementing the non-communicable diseases global action plan 2013–2020: a synthesis of WHO country profile reports.BMC Public Health. 2017; 17: 297Crossref PubMed Scopus (55) Google Scholar Bollyky and colleagues' findings suggest a possible reason for this dispiriting reality: many of the countries with the worst health systems are governed by corrupt autocrats who retain power by force and can ignore the welfare of their people without repercussions. To date, the global development community has skirted the complications of politics, instead emphasising medical programmes and the empowerment of women, the LGBT+ (lesbian, gay, bisexual, transgender, and all other identities) community, and people with disabilities—ie, people who do not directly challenge government power. This emphasis is sometimes justified by the longstanding assumption that in poor countries, especially, dictators are better at getting things done because they can ignore the demands of petty, competing constituencies.10Przeworski A Alvarez ME Cheibub JA Limongi F Democracy and development: political institutions and well-being in the world, 1950–1990. Cambridge University Press, Cambridge2000Crossref Google Scholar However, Bollyky's findings support the theory that dictators might themselves be a cause of poverty and illness, and that democrats, however befuddled and disorganised, better serve their people. Unfortunately, the rights of pro-democracy activists are routinely violated with impunity, especially in those African countries most beset by poverty and ill health.11Epstein H. Another fine mess: America, Uganda and the war on terror. New York: Columbia Global Reports, 2017.Google Scholar Recent elections in Kenya, Uganda, Ethiopia, Rwanda, the Democratic Republic of the Congo, Gabon, Cameroon, and Zimbabwe were all marred by credible rigging allegations, which donors, in most cases, dismissed. When two opposition members of parliament in donor darling Uganda were beaten and crippled by security forces inside parliament in September, 2017, not one international donor or human rights organisation spoke out.12Epstein H The US turns a blind eye to Uganda's assault on democracy.The Nation. July 20, 2018; Google Scholar Global health advocacy groups need to do more than clamour for more funding and occasionally bemoan corruption. They need to call on Washington (USA), Brussels (Belgium), London (UK), and other donors to impose sanctions on dictators, including those who cooperate with western military aims. As Rudolf Vichow, one of the pioneers of modern public health, wrote after witnessing the ravages of typhus on the oppressed peasants of Silesia, “politics is nothing but medicine at a larger scale”.13Virchow R Der Armenarzt.Medicinische Reform. 1848; 18: 125-127Google Scholar I declare no competing interests. The relationships between democratic experience, adult health, and cause-specific mortality in 170 countries between 1980 and 2016: an observational analysisWhen enforced by free and fair elections, democracies are more likely than autocracies to lead to health gains for causes of mortality (eg, cardiovascular diseases and transport injuries) that have not been heavily targeted by foreign aid and require health-care delivery infrastructure. International health agencies and donors might increasingly need to consider the implications of regime type in their efforts to maximise health gains, particularly in the context of ageing populations and the growing burden of non-communicable diseases. Full-Text PDF Open Access