Health and Development

1. Health and Development March 28, 2011 Akanksha Bajaj, Aaron Lewis, Mattie Wheeler

2. Image Source: WHO Fact Sheets

3. Key Facts • Nearly 9 million children under the age of 5 die every year • Around 70% of these early child deaths are due to conditions that could be prevented or treated with access to simple, affordable interventions • Over one third of all child deaths are linked to malnutrition • In low-income countries less than a quarter of all people reach age of 70, and people die predominantly of infectious diseases

4. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without the distinction of race, religion, political belief, economic or social condition. -WHO Constitution

5. UN Millennium Development Goals

6. Death Distribution & Child Mortality Image Source: WHO Fact Sheets

8. Why Study Health and Development? • Preston curve: strong correlation between per capita income and life expectancy, but is there a causal relationship between poor health and low GDP per capita? • Poverty trap? Income is a function of health, but health is also a function of income • Wealthier is Healthier (Pritchett & Summers, 1996): Higher income leads to good and services that promote health, such as better housing, better nutrition, more education, as well as public health projects • Better health allows adults to earn more income and children to perform better on tests • Health is also correlated with income within countries – these are called “health inequalities” • Researchers need to understand the relationship between health and development in order to determine the most effective policy intervention. • Is it more effective to focus on programs that raise GDP without specifically focusing on health care? • Or should we target health through large public health initiatives like vaccination campaigns or large-scale sanitation projects?

9. Key Questions about Health and Development • Are health improvements an instrument for achieving economic growth? That is, does better health cause an increase in GDP per capita or just an increase in “overall welfare”? • Does increasing GDP per capita cause better health (i.e. increased life expectancy) or are separate measures necessary? • What are the barriers to better health in poor countries and how much of a role do they each play? • Lack of infrastructure • Lack of funding • Lack of political will • Lack of education • What are the most effective ways to improve health in developing countries? • Vaccination • Medicine distribution (i.e. antibiotics) • Public health projects like waste removal or water sanitation • Construction of medical clinics • Education (particularly of women)

10. The Determinants of MortalityCutler, David, Angus Deaton and Adriana Lleras-Muney ProponentSection

11. The Preston Curve: Life Expectancy versus GDP Per Capita

12. Historical Decline in Morality: Introduction • Little increase in life expectancy from hunter-gatherers to 1700 • Significant mortality decline begin in 18th century • Most of historical reduction in mortality occurred at younger ages • Pattern explained by decline in infectious diseases • Between 1848 and 1971, 95% reduction in infectious disease mortality • Infants and children are most vulnerable to infections • What are the relevant factors in reduction of infectious diseases?

13. Expected Age at Death, England and Wales

14. Historical Decline in Mortality: Possible Causes • Improved Nutrition • Public Health • Urbanization • Vaccination • Medical Treatments • Long-Term Reach of Early-Life Factors (also known as the “womb with a view” hypothesis)

15. Historical Decline in Mortality: Improved Nutrition • McKeown 1976: residual analysis showing nutrition as crucial factor; however, unconvincing. • Fogel 1997: used increase in caloric intake (measured in agricultural output and changes in adult height) to show that nearly all reduction in mortality attributed to improved nutrition • Arguments against Fogel: • Life expectancy was the same in 1600 and 1820 • Skeletal remains show people were taller during the early medieval times • English aristocrats had no higher life expectancy than rest of population, despite better nutrition • Two way interaction between disease and nutrition—so some of the exogenous influence was disease, not just nutrition, and therefore interventions that targeted disease (such as public health) were more significant

16. Historical Decline in Mortality: Public Health • Preston estimates: only 15% of increase in life expectancy between 1930s and 1960s in result of increases in only income • Even at a given income, people live significantly longer today than in the past • Public health offers an explanation for this • Macro public health: big public works projects • Micro public health: change encouraged by public sector but carried out by individuals • Acceptance of germ theory of disease in 1880s led to new public health initiatives

17. Historical Decline in Mortality: Urbanization • Most evidence shows urbanization caused lack of improvement in mortality in mid-19th century • Greater spread of disease in large cities • Effect of unsanitary conditions > nutrition effect

18. Historical Decline in Mortality: Vaccination • First important medical intervention began early 20th century • Important vaccines: • Rabies, plague, diphtheria, pertussis, tuberculosis, tetanus, yellow fever, polio, measles, mumps, rubella, hepatitis B • However, direct mortality from these diseases was somewhat rare prior to introduction of vaccines • Reduction in these diseases as causes of death represent only 3% of total mortality reduction (excluding tuberculosis) • Indirect consequences of eliminating infectious diseases

19. Historical Decline in Mortality: Medical Treatments • Development of new treatments for people with diseases • Antibiotics, developed 1930s-1940s caused • Other intensive medical medical interventions targeting cardiovascular disease • Infectious disease mortality declined to current level by 1960 • Cardiovascular disease mortality has declined by over 50% since 1960 • Reduced infant mortality due to neonatal care • Concurrent decline and convergence of mortality rate in developed countries shows importance of medical technology and smoking behavior • Today, according to Fogel, health care system is important for reducing morbidity but not mortality

20. Historical Decline in Mortality: Fetal Origins • Better nutrition from decades ago is having its effect today • Correlation between health in adulthood and birth weight, even when controlling for socioeconomic status • What other approach could researchers take to test the fetal origins theory? • Examine late-life health of children who were in utero during famines • Seasonality of life expectancy • Environment during childhood predicts onset of disease in adulthood • Some of decline at end of 20th century can be attributed to improved diet and public health during childhood

21. Historical Decline in Mortality: Conclusions • Three phases in mortality reduction: • Mid-18th to mid-19thc.: improved nutrition and economic growth played large role • End of 19th-20thc.: public health mattered more • Negative effect of urbanization • Positive effect of clean water, waste removal, personal health advice • 1930s-present: medicine, including vaccinations, antibiotics, personal interventions

22. Determinants of Mortality in Poor Countries

23. Determinants of Mortality in Poor Countries • 30% of deaths in poor countries are children, compared to <1% in rich countries • Most deaths in poor countries are from infectious disease, instead of cancer and cardiovascular disease • Improvement in life expectancy since WWII: • India and China rose by 30 yrs • Life expectancy in Africa rose 13 years until 1980s • How to account for this improvement? • Still, great inequality between health in poor and rich countries • Not primarily due to lack of treatment

24. Determinants of Mortality in Poor Countries: Risk Factors • Risk factors for mortality in poor countries (according to WHO 2003) • Unsafe sex • Unsafe drinking water • Malnutrition • Indoor smoke • What affects these risk factors? • Low quality and inadequate funding of health delivery • Lack of political demand for improvement in health provision • Successful interventions have mostly been “vertical” campaigns • These do not improve domestic health care systems • Current lack of support for international immunization campaigns  slowdown in rate of reduction of infant mortality in 1990s • Importance of social factors • Changes in income and literacy

25. Determinants of Mortality in Poor Countries: Economic Growth (1/2) • Assuming Preston curve is causal relationship, effects of income on health are strong at low levels of income • Emphasis on nutritional factors as well as infrastructure of public health • Pritchett and Summers (1996): used cross-country regressions to show income is most important factor • This explanation favors policy that downplay role of deliberate health intervention, such as economic liberalization • However, cross-country data shows no relationship between changes in life expectancy and economic growth between 1960 and 2000 • India and China actually show negative correlation between economic growth and reducing infant and child mortality

26. Determinants of Mortality in Poor Countries: Economic Growth (2/2) • Why doesn’t economic growth improve health without deliberate public action? • Paradoxical because income can bring better nutrition, better housing, ability to pay for public health projects • Possible explanations? • Acemogluand Johnson (2005): improvements in health technology actually reduce GDP per capita if they lead to large increases in population • Effect of economic growth on health has been hidden by negative effects of population growth in WWII period

27. Determinants of Mortality within Countries: Introduction • Evidence from different time periods and counties all show higher mortality rate for individuals with low income, low education, low social status • In United States, inverse correlations between education, income, and mortality • Similar gradients in developed countries • World Bank study shows negative link between infant mortality and index of living standards (lack of data on adult mortality in poor countries) • Why do these inequalities exist? Are they consistent with accounts of mortality decline and differences in mortality between rich and poor countries?

28. Determinants of Mortality within Countries: Medical Care & Resources • People with high income receive more health care • However, studies show that incidence of health conditions is higher among lower social classes (before health care system is even a factor) • EX: Britain’s class-based differences in health were not affected by National Health Service • No evidence rising living standards change the health gradient

29. Determinants of Mortality within Countries: Health-Related Behaviors • Smoking, drinking, exercise, eating habits, use of preventative care all correlated with measures of socioeconomic status • However, even when these differences are controlled for, health gradients by status persist • Also does not explain why people from different socioeconomic classes behave differently • EX: due to widespread campaign, knowledge of detrimental effects of smoking in the U.S. is nearly universal

30. Determinants of Mortality within Countries: Social Structures, Stress and Health • Poor health of low status people is due to “psychosocial stress” • Supported by biological evidence • Cumulative stress leads to increased probability of disease • Concerns with this theory: • Socioeconomic status encompasses a range of variables like income, education, race, and this explanation does not differentiate between them • Reverse causality  poor health leads to low income • Poor health is leading cause of retirement or dropping out of the labor force • Effects of education more consistent than effects of income with regard to socioeconomic status • Numerous studies show correlation between maternal education and reduction in infant and child mortality in developing countries • However, also possibility of reverse relationship because children who have poor health enter adulthood with lower educational achievement

31. Determinants of Mortality within Countries: Conclusions • In many cases, poor health causes low income, rather than the reverse • Direct positive effect of education on health • This also means that some of post-1970 decline in mortality in U.S. can be attributed to education, meaning less attributed to medical care

32. The Determinants of Mortality: Final Conclusions • Acknowledgement that evidence is weak for many links in argument • Explanation for decline in mortality: knowledge, science, technology • Critical role of germ theory of disease in changing public health and personal behavior • Increased productivity allowed better nutrition, better housing, better sanitation • Knowledge of effects of smoking • Scientific innovations in medical procedures, drugs • Health innovations for poor countries: oral rehydration salts, freeze-dried serums • Role of income less important • Improvements in income and health come from new ideas and new technology • Public health initiatives require institutional capacity and political willingness to implement new technology, not just income • Lower income explains much of correlation between income and health • Great incentives for discovery of health-enhancing knowledge and technology • But, these will increase gradient • Greater speed of introduction of knowledge and technology will raise health gradient • Gaps between countries may also widen, since there is less incentive for research and discovery of diseases that affect the poor (such as malaria and tuberculosis) • The existence of treatment does not mean that it will be made available in poor countries • Goal of public policy should be to improve equality of access to such technologies