Life quality across structural change

 

Periods of rapid structural change are particularly likely to lead to decline in the quality of life of some sections of the affected population. Change creates winners and losers; and it is common that the gains and losses are channeled into very distinct groups of people.  This is true during periods of large-scale migration, technology change, and structural change within an economy. Important components of life quality include health, nutrition, education, economic wellbeing, economic security, and security from violence and coercion. Each of these properties is affected by several important dimensions of social life:

  • legal and political institutions
  • institutions of economic production and distribution
  • economic opportunities and income
  • public provision of income supplements
  • public provision of food subsidies
  • public provision of health care resources
  • household support provided by family and community

When a society’s governmental and economic institutions are enmeshed in a period of rapid change, many of the components of life quality are likely to be affected — positively or negatively. The basic institutions of a society determine the value of the private and public assets individuals and households control on the basis of which to support their pursuit of a decent life; this is what Amartya Sen refers to as “entitlement bundles”. (Sen applies his entitlement theory to the study of famine in Poverty and Famines: An Essay on Entitlement and Deprivation; link.) And shifts in the composition of the entitlement bundle are likely to lead to abrupt worsening of the conditions of the least-well-off.

For example: It is likely that the austerity policies of the Spanish or Greek governments will have a negative effect on the health and nutritional status of the bottom half of those societies. Working people will have lower incomes and they will have reduced access to the social safety net; health status is likely to decline. As another example: Life expectancy in the former Soviet Union declined measurably following the collapse of the Soviet system (link). One part of that decline was the disappearance of the social security net created by state-owned industry — the smashing of the “iron rice bowl”.

This concern is particularly relevant in the context of the rural-urban transformation currently underway in China. Since 1980 China’s rural sector has been subject to at least two major kinds of structural change. One has to do with the economic and political institutions that governed daily life for rural households, from communes to market institutions. And the other has to do with the rapid structural transformation of China’s economy from agriculture to export-led manufacturing. The first set of changes led to a withdrawal of forms of “social insurance” that had been associated with the commune system, including healthcare and old-age care. The second has led to mass migration of younger workers from villages and towns to factories in cities. This migration leaves the remaining population in the countryside older, poorer, and less economically secure.

These observations have several important implications. Foremost among these is the crucial importance of maintaining effective systems for monitoring and measuring life quality across the society. It is important to have good measures of health status, nutritional status, educational status, and old age life quality across regions and sub-populations. So national governments need to create and fund the social research activities necessary to measure health and other quality of life properties across the population. (Here is a recent post on a spatial study of quality of life in China based on 1982 data; link.) Sen argues that it was the availability or lack of availability of information about famine conditions that explained the difference in outcomes between China during the Great Leap Forward and post-independence India; Poverty and Famines: An Essay on Entitlement and Deprivation.

Second, when it turns out that there are large numbers of “losers” in a large social process of change, it is important for the state and non-governmental actors to find institutions and resources that will help to improve their outcomes. “Winners” need to help to fund the amelioration of harms created by the processes that led to their gains. If NAFTA led to the increase of overall national income for Canada, Mexico, and the United States, but also led to the displacement of workers in a significant set of industries — then it makes sense to tax part of those gains to compensate the losers. And in fact, the NAFTA agreements were premised on such compensation, though this has not occurred reliably (link). This means redistribution across sectors and regions; and it is justified by the fact that the overall gains created by the transformation would not have been possible without imposing these losses on the disadvantaged sector or region.

What might this kind of redistributive policy look like in the context of China’s rural-to-urban transformation? It would seem that public moneys will be needed for several types of problems:

  • Maintenance of income and quality of life and health for the elderly
  • Investments that increase the productivity of labor and the level of employment in rural areas
  • Investments that work to ameliorate the negative environmental effects of rapid change
  • Investments in the institutions of public health — clinics, hospitals, and medical personnel

It might be asked, “Why should developing nations concern themselves with this issue?” There are several answers. Basic justice and fairness entails that the wealth of a society should be distributed in ways that allow all segments of society to improve their quality of life and wellbeing. A society’s wealth and income is a joint product of its entire population; so fairness dictates that everyone should benefit from improvements in productivity. But prudence lines up with this answer as well. A society that ignores the widening of the gaps between rich and poor, and does not concern itself about improving the wellbeing of the poor, is likely to suffer a rising level of social strife as well. It can either go the route of creating gated communities for the rich, or it can use its resources to create fair life outcomes and fair access to opportunity for all its people. Everyone is better off in the long run with the second choice.

In The Paradox Of Wealth And Poverty: Mapping The Ethical Dilemmas Of Global Development I argued that a developing nation should choose an economic development strategy that spreads the benefits of growth over a broader population, over a strategy with a higher growth rate but with substantially greater inequality. I still think this is the right answer to the question. And this approach has the best likelihood of improving the quality of life of the poorest segment of society. The graphs below make the case based on three stylized strategies:

  1. NL neo-liberal growth: choose those policies and institutional reforms that lead to the most rapid growth: unfettered markets, profit-maximizing firms, minimal redistribution of in­come and wealth 
  2. PF poverty-first growth: choose those policies and institutional reforms that lead to economic growth favorable to the most rapid growth in the incomes flowing to the poorest 2 quintiles 
  3. WF immediate welfare improvement: direct as much social wealth as possible into programs that immediately improve the welfare of the poor (education, health, food subsidies, housing subsidies)  
 

The neo-liberal strategy consistently maximizes GDP; but the poverty-first strategy, which is more redistributive from the start, leads to consistently better improvement for the income for the bottom 40% of the economy.  It embodies the idea that Hollis Chenery advocated forty years ago in Redistribution with Growth: Policies to Improve Income Distribution in Developing Countries in the Context of Economic Growth.

Health disparities in the US and China


Health disparities across a population are among the most profound indicators of social inequalities that we can find.  And the fact of significant disparities across groups is a devastating statement about the circumstances of justice under which a society functions.  These disparities translate into shorter lives and lower quality of life for whole groups of people, relative to other groups.

Both the United States and China appear to display significant health disparities across their populations. Here are a couple of studies that draw attention to these facts.

United States

Here is an important new study on the question of health disparities in the United States by public health researchers at Harvard and UCSF.  The study is “Eight Americas: Investigating Mortality Disparities across Races, Counties, and Race-Counties in the United States”. And the answer the researchers provide to the question above is that the US possesses very significant health disparities across segments of its population. The study is worth reading in detail.

The authors analyze mortality statistics by county, and they break the data down by incorporating racial and demographic characteristics. The data groups fairly well around the eight Americas mentioned in the title:


Here is how they describe their findings:

The gap between the highest and lowest life expectancies for race-county combinations in the United States is over 35 y. We divided the race-county combinations of the US population into eight distinct groups, referred to as the “eight Americas,” to explore the causes of the disparities that can inform specific public health intervention policies and programs.

And here is their conclusion:

Disparities in mortality across the eight Americas, each consisting of millions or tens of millions of Americans, are enormous by all international standards. The observed disparities in life expectancy cannot be explained by race, income, or basic health-care access and utilization alone. Because policies aimed at reducing fundamental socioeconomic inequalities are currently practically absent in the US, health disparities will have to be at least partly addressed through public health strategies that reduce risk factors for chronic diseases and injuries.

For example, their data show that “the life expectancy gap between the 3.4 million high-risk urban black males and the 5.6 million Asian females was 20.7 y in 2001.” This is an enormous difference in longevity for the two groups; and it is a difference that tags fundamental social structures that influence health and risk across these two populations.

Here is a time-series graph of the behavior of longevity for the eight Americas:
So what are the factors that appear to create these extreme differences in mortality across socioeconomic and racial groups in America? They consider health care access and utilization; homicide; accidents; and HIV as primary potential causes of variations in mortality for a group. Most important of all of these factors for the large populations appear to be the health disparities that derive from access and utilization.  And here they offer an important set of recommendations:

Opportunities and interventions to reduce health inequalities include (1) reducing socioeconomic inequalities, which are the distal causes of health inequalities, (2) increasing financial access to health care by decreasing the number of Americans without health plan coverage, (3) removing physical, behavioral, and cultural barriers to health care, (4) reducing disparities in the quality of care, (5) designing public health strategies and interventions to reduce health risks at the level of communities (e.g., changes in urban/neighborhood design to facilitate physical activity and reduce obesity), and (6) designing public health strategies to reduce health risks that target individuals or population subgroups that are not necessarily in the same community (e.g., tobacco taxation or pharmacological interventions for blood pressure and cholesterol).

These findings are squarely relevant to assessing the justice of our society. The country needs to recognize the severity of the “health/mortality equity” issue, and we need to make appropriate policy reforms so that these disparities begin to lessen.

China

Several research papers address these issues for the case of China.  One is a World Bank working paper by David Dollar called “Poverty, Inequality, and Social Disparities During China’s Economic Reform” (link).  Dollar notes that China has dramatically reduced its poverty rate over the past 25 years, whereas its income inequality measures have increased sharply during the same period. (Albert Park and Sangui Wang review the poverty statistics for this period in China Economic Review; link.)  They conclude that these inequalities between rural and urban populations, and between well educated urban professionals and the urban working class, have also resulted in significant inequalities in health status and outcomes for the various sub-populations.

Shenglan Tank, Qingyue Meng, Lincoln Chen, Henk Bekedam, Tim Evans, and Margaret Whitehead review the current evidence available on health equity in China in “Tackling the challenges to health equity in China” (link).  “Although health gains have continued, concern for the equitable distribution of social benefits of economic progress has grown” (25).  Further:

Disparities in income and wealth between the urban and rural areas, between the eastern and western regions, and between households have widened substantially. In 1990, the richest province had a GDP per person more than seven times larger than the poorest province, but by 2002, the same ratio had grown to 13 times greater.41The Gini coefficient, a measure of income inequality,42increased for China as a whole from 0·31 in 1978–79 to 0·45 in 2004. The level of income inequality in China is now similar to that in the USA, roughly comparable to that in the most inequitable Asian countries—Philippines and Thailand—and approaching the notoriously inequitable levels in Brazil and Mexico. (29-30)

The authors quote Amartya Sen on health equity (Amartya Sen, Why health equity”; link):

Health equity cannot be concerned only with health in isolation. Rather it must come to grips with the larger issue of fairness and justice in social arrangements, including economic allocations, paying attention to the role of health in human life and freedom.  Health equity is most certainly not just about the distribution of health, not to mention the even narrower focus on the distribution of health care. Indeed, health equity has an enormously wide reach and relevance.

And inequalities in personal income in different provinces lead to highly different levels of ability to fund public amenities in these provinces, with large effects on public health in poor provinces:

Living conditions differ greatly between areas of different affluence. Safe drinking water is available to 96% of the population of large cities but to less than 30% in poor rural areas. Differences in access to effective sanitation are even larger, 90% of residents in large cities have adequate sanitation, compared with less than 10% in poor rural areas (figure 6).

Two graphs capture the big picture:

 

In figure 1 the data demonstrate a strong correlation between life expectancy and average income for China’s provinces and municipalities, from just about 65 years for the poorest regions to 78 years in Shanghai region.  Figure 2 demonstrates major inequalities in child health between rural and urban locations.  The authors further report that infant mortality also varies dramatically across regions: “Rural infant mortality rates are nearly five times higher in the poorest rural counties than in the wealthiest countries — 123 versus 26 per 1000 live births, respectively” (26). One important source of data on these issues that these researchers use is the Chinese National Health Service survey of 1998; link.

The most detailed analysis of health disparities in China I’ve been able to find is a paper published in 2010 by Feinian Chen, Yang Yang, and Guangya Liu, “Social Change and Socioeconomic Disparities in Health over the Life Course in China: A Cohort Analysis” (link).  They make use of the China Health and Nutrition Survey to allow for a longitudinal study of health in several segments of China’s population. (Here is a description of the CHNS.) Their conclusion:

Using data from the China Health and Nutrition Survey, we find significant socioeconomic status (SES) differences in the mean level of health and that these SES differentials generally diverge over the life course. We also find strong cohort variations in SES disparities in the mean levels of health and health trajectories. (126)

It would appear that studies of health status in China disaggregated by population segments are not yet as fully developed as one would wish.  The CHNS appears to have limited data coverage (much more limited than the national census, for example), and none of the studies mentioned in these articles appear to disaggregate down to levels lower than the province.  But the summary findings of all three of these articles point in the same direction: it is probable that there are significant inter-regional and inter-sectoral inequalities in health outcomes for the sub-populations corresponding to these segments.

%d bloggers like this: