A Dose of Democracy Benefits Public Health

The quality of democracy was linked with greater government spending and lower mortality from cardiovascular disease, but not with higher gross domestic product (GDP) per capita, an observational analysis found.

Controlling for HIV/AIDS, the average adult life expectancy improved quickly and increased by an average of 3% after a decade of democratic transition, reported Thomas Bollyky, JD, of the Council on Foreign Relations in Washington, and colleagues in the Lancet.

The democratic experience accounted for more of the variation in death within the country than GDP for cancers (9.50% vs 6.07%), transport injuries (17.78% vs 6.65%), cirrhosis (6.14% vs 2.18%), cardiovascular diseases (22.27% vs 11.83%), and other noncommunicable diseases (12.68% vs 9.14%), like congenital birth defects and congenital heart disease. The democratic experience accounted for the greatest proportion of variation in death for the democratic experience for transportation injuries and cardiovascular diseases, the investigators found.

However, the removal of fair and free elections from the democratic process ended the relationship between age-standardized mortality from injuries and noncommunicable diseases, they noted.

The degree to which a country’s democratic experience affects population health has been poorly interpreted, according to the authors. Nearly all of these studies have focused on democracy’s effect on the mortality of children under age 5 years, infants, or life expectancy at birth. These papers reflect gains in infant and child health, and have provided contradictory findings, the authors stated.

Specifically, the investigations have been unable to determine whether country income, quality of government institutions, or the democratic process is impacting health, Bollyky’s group noted.

Based on their findings, the democratic experience may be an effective approach to jump starting the betterment of country-led progress for adult health, and to improving political transparency, political will, and accountability, the researchers noted.

“One option for proceeding is increasing the funding for the development agency-led programs for democracy promotion and governance that already exists in many European nations, the USA, and Canada, and their variants at the World Bank and other intergovernmental institutions,” they emphasized.

Another avenue might be “directing more of the scarce development assistance for health for causes where democratic experience matters, such as cardiovascular diseases, tuberculosis, or transport injuries to the nations that have shown a commitment to building accountable institutions and open and transparent democratic processes,” the investigators said

Although most public health officials and clinicians are aware that the health issues affecting populations around the world and in the U.S. are political, noted Bollyky, “our current global health goals focus on issues, such as universal healthcare to tobacco taxes or the affordability or accessibility of cancer drugs, and these are all issues that are political questions.”

“They involve the role of the state and society, and the balance of individual and collective and commercial interest … ignoring the role of open and accountable government or civil society or free media in resolving those debates is unsustainable,” he told MedPage Today. “We need to pursue global health in a manner that reflects that governance matters for the future welfare of the populations that we are seeking to improve.”

Study Details

Bollyky’s group reviewed a panel of information on 170 countries over 46 years to evaluate the effects of democracy on population health and to explore pathways linking health gains and democratic rule. The investigators also looked at the association between life expectancy at 15 years and between cause-specific mortality and democracy.

The researchers gathered HIV-free life expectancy and cause-specific mortality approximations using the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 and regime related information from the Varieties of Democracy initiative. Using the Financing Global Health dataset, the investigators also gathered gross domestic product per capita, and domestic health spending approximates from 1995 along with Development Assistance for Health approximates beginning in 1990.

Bollyky’s group used a variety of empirical methods, including structural equation models, fixed-effects regression, synthetic control, and within-country variance decomposition, which combined, contribute to a robust analysis of the link between population health and democratization.

The authors noted that, over 2 decades, the data showed the average nation’s rise in democratic experience had indirect and direct effects on lowering death due to tuberculosis (–8.93%, 95% CI –2.08% to –15.77%), cardiovascular disease (–9.64%, 95% CI –6.38% to –12.90%), and other non-communicable diseases (–9.14%, 95% CI –4.26% to –14.02%).

They also found that increases in a nation’s democratic experience were not related with GDP per capita from 1995 to 2015 (rho –0.1036; P=0.1826), but were related to increases in governmental health spending (rho 0.4002; P<0.0001) and to decreasing mortality from cardiovascular disease (rho –0.3873; P<0.0001).

The study had limitations, such as the the difficulty in measuring the link between democracy and population health because of democracy’s ties to other factors, such as country income or total health expenditure. Bollyky added that “there is no way to do a randomized trial on democracy.”

He cautioned that “these disease-specific mortality estimates are estimates. I think people feel that mortality estimates are fairly reliable, but they are estimates. Of course, there are lots of countries in the world that don’t have vital registration information that tracks, in a comprehensive way, what people are dying from.”

‘Befuddled and Disorganised’

In an accompanying editorial, Helen Epstein, PhD, of Bard College in Annandale-on-Hudson, New York, said that “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.”

The current findings build on previous research by the authors that “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,” Epstein noted.

She also pointed out that the 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.”