Democracy and health

Political institutions and health

Scholars of population and global health have grappled for decades with the complex relationship between health and its determinants. This growing literature has taught us much about proximal and distal health determinants, especially those in the socio-economic realm. Economics as it relates to health, in particular, has received considerable and recent investigation,¹ but mounting evidence suggests that a country’s economic status alone cannot entirely explain differences in health and health policy.^2–8 Thus, societies with similar levels of economic development, such as Afghanistan and the Indian state of Kerala, can have radically different levels of health and health system development. It is therefore important to extend our analysis to broader structural factors, such as political institutions, to better understand global health inequalities. A country’s political structure affects virtually every aspect of society, including health.

There are few studies on the relationship between political institutions and health, at both theoretical and empirical levels^9–11. One reason must certainly stem from the complexity of the health-politics nexus and the difficulty of identifying independent and interactive influences in both directions. The relationship can be defined in many ways, ranging from the study of political systems (e.g. democratic or authoritarian, legislative and executive governance, proportional or majoritarian electoral systems, constitutional structure); culture (e.g. political values); institutions (e.g. centralized or fragmented, presidential or parliamentary, responsiveness to citizenry, political parties); state capacity (technical and administrative capacity, level of corruption); and philosophy, to more nuts-and-bolts political process factors, such as personal politics (e.g. political leadership, powerful personalities, presidential tactics), political strategy and interest group representation (e.g. its strength or weakness in a political system). More recent influences on health policy include re-election incentives, financial contributions (e.g. in the US), and the depth and range of public opinion.^12,13 A recent issue of the British Medical Journal has brought attention to politics as a determinant of health, and this work begs a theoretical and philosophical framework for understanding the mechanisms through which political institutions impact health.^9–11,14,15

One theory that relates political institutions to human development focuses primarily on democratic principles, such as regular elections, universal suffrage, representation, one person–one vote, multiparty competition, and civil liberties.¹⁶ In this realm of thinking, representative democracy is generally understood to produce competition for popular support among elites who are trying to maintain or win elected office,¹⁷ although some argue that politicians’ responsiveness to citizens’ needs and concerns has waned in some settings.¹² Democratic institutions might therefore relate to health through, for example, alleviation of social disparities and income inequalities that results from greater political voice and participation.^18–20 Improving the health of the worst-off can in turn improve a country’s aggregate performance in health. Political institutions might also affect health through their general impact on universal health policy issues, such as universal access to high-quality services. In such cases, political institutions might help create universal health insurance and access programs such as the British National Health Service or the Canadian Health Insurance System.^21–23

By contrast, the absence of representative democracy provides few incentives for political elites to compete for votes,²⁴ resulting in less political responsiveness and fewer incentives to spread benefits universally or to the poor. Authoritarian regimes suppress political competition and tend to have an interest in preventing human development, because improved health, education, and economic security mobilizes citizens to advocate for greater participation and more resources.

While much can be said about the link between politics and health, this paper examines one aspect of this relationship—the impact of key democratic principles on health. After presenting a philosophical framework that links democracy and health, it analyses three major public health events in China: the 1958–1961 famine, the SARS epidemic, and the emerging threat of HIV/AIDS. These three case studies explore the idea that a lack of democratic institutions, especially a free press and multiparty elections, can have deleterious effects on health.

A philosophical framework linking democracy and health

The link between democracy and health can be viewed through a philosophical framework, which sees societal development as expanding individual freedoms, and focuses on two basic aspects of freedom: opportunity and process.⁵ The opportunity aspect judges public policy by its impact on individuals’ substantive freedoms or capabilities: for example, its impact on individuals’ capability to avoid premature mortality, preventable morbidity, or involuntary starvation.^5,7,25–27 The process aspect stipulates that public participation in political decisions and social choice is a constitutive part of public policy.

This philosophical framework focuses on enhancing individuals’ agency or ability to understand and ‘shape their own destiny and help each other.’⁵ In this paradigm, citizens make their own decisions as active agents of change, and state actions must be evaluated in terms of their effectiveness in expanding individual freedom. As Amartya Sen has demonstrated,⁵ such freedom can be realized, in part, through a multiparty democracy, with elections and free media, open public debate and discussion, and guaranteed individual civil and political rights. In such a framework, health is an intrinsically valued end of development and public policy and is also a means to other valuable ends.^6–8,25 The same can be said of political freedoms. Applying this framework to developing countries reveals widely different political, economic, and social contexts. Analysing public health episodes in China in historical perspective within this framework reveals a political and cultural history of authoritarianism, and a lack of civil liberties, political rights, and freedom of the press that have dramatically impacted the population’s health.

China’s famine of 1958–1961

Between 1958 and 1961, one of the largest famines in recorded history killed nearly 30 million people in China.^28–31 This tragedy followed the famous Great Leap Forward, which was initiated, in part, to improve the health of the Chinese people. Many have sought to explain this paradox and the resulting health disaster. The country’s authoritarian and undemocratic political system is considered a leading reason why the government failed to respond quickly and effectively to public need.^28,29

The Chinese government received little pressure to report the famine, because the absence of an opposition group and the lack of open journalism created an uninformed public.²⁹ Furthermore, the government did not admit the failure of the Great Leap Forward for several years. This motivated government leaders to exaggerate crop yields, to give the impression that agricultural and rural economic policies were successful. During the height of the famine, Chinese authorities noted they had 100 million more metric tons of grain than they actually had.²⁹ This misconception kept Chinese imports of food grains down while food grain exports peaked. In 1959, China imported about 2000 tons of food grains, compared with 223 000 tons in 1958.²⁹ During the same period, exports of food grains peaked in 1959 at 4.2 million tons, up from 1.9 million tons in 1957 and 2.7 million tons in 1958.²⁹

China’s famine was also associated with a decline in food production. The average national grain output per capita in 1956–1957 was 308 kg, which fell by 17% in 1959 and reached its lowest level—a decline of approximately 30%—in 1960.²⁹ However, the rural population suffered much more than the urban population, because the government moved food from rural to urban areas. In one province, grain availability was 288 kg per head in an urban area but only 122 kg per head in rural areas.²⁹ Additionally, food procurement from rural areas rose from 17% in 1957 to 21% in 1958 and 28% in 1959.²⁹ Thus, people in rural areas had to part with a larger proportion of their output. The culprit in this case was the political system, as the famine was not made public for three years, and there were no official policies for responding. The primary feature of the Chinese government, an ‘absence of adversarial politics and open journalism,‘²⁹ contributed to the largest famine in history.

Sen has argued that political freedoms can help prevent major social disasters such as widespread famine because the existence of free, uncensored media draws attention to social needs and allows government policies to be evaluated openly. Similarly, democratic elections (with a choice of parties) forces the party in power to justify its policies or reform them in accordance with people’s needs. Sen argues that China’s inability to prevent the famine of 1958–1961 resulted in part from its lack of a free, uncensored press and the absence of opposition parties that would have poked holes in the government’s propaganda, false reports, and failed reform policies. Instead, the government continued to pursue a set of harmful policies. A key aspect of this argument is that the lack of a free press actually ‘misled the government itself‘⁵ because state policy was dictated by the government’s own dogma and by inaccurate reports from local Communist Party officials who were competing for ‘credit in Beijing.‘⁵ Sen notes that this campaign of distortion and misinformation led the government to vastly overestimate the country’s food supply.^5,28,29,31

Why China mishandled SARS

More recently, China’s lack of democratic freedoms made it unable to respond promptly to a new health crisis: Severe Acute Respiratory Syndrome (SARS). The government’s immediate response to SARS was reminiscent of its reactions to the famine 40 years before. Its first inclination was to cover up, rather than reveal, both the scope and severity of the disease, thwarting control efforts. For example, the government’s censorship of news about the spread of SARS in Guangdong Province in 2003, which accelerated the spread of the disease,^32,33 was possible because the Communist Party directly controlled the media. Had citizens been made aware of SARS earlier through accurate reporting of its prevalence and geographic spread and evidence-based prevention and treatment recommendations, they would have known how to take precautions and obtain needed care. The government was exceptionally vigilant at first however, about hiding evidence of SARS through heavy-handed propaganda and control of information. It also threatened citizens with execution and lengthy imprisonment should they become infected with or knowingly spread SARS.³⁴ And there was forceful suppression of opposition or anti-government sentiment as well as infringements of civil liberties.

The Chinese government’s pledges of honest reporting of infections and firing of public officials (e.g. firing both the mayor of Beijing and China’s health minister) at first brought hope for real political reform,³⁵ but subsequent efforts fell short of that goal. Far from acting as an independent and free agent, the Communist Party’s newspaper, People’s Daily, instead served as a Party instrument by publicly praising government leadership and strategies and misreporting public opinion. For example, it noted that ‘the people have become more trusting and supportive of the party and government.‘³⁴

An ironic twist to the SARS story is that China made a successful transition to a more open, internationally connected, market-oriented economy but failed to capitalize on the simultaneous global movement for democratization. This change exacted a high price from China and the global community because, unlike the 1958–1961 famine, China’s SARS epidemic fatally impacted the rest of the world. Consequently, China’s failure to contain and effectively address SARS exposed it to international criticism and provided a strong rationale for sovereign nations and global institutions such as the World Health Organization (WHO) to become more actively involved in its political economy. Indeed, the ripple effect of the SARS crisis penetrated the international development community itself, forcing WHO to consider reforms that would allow it to ‘fight future international threats’ more powerfully.³⁶ Thus, while China’s handling of SARS has many similarities to the famine of the mid-twentieth century, those similarities remain primarily domestic. In today’s more integrated global economy, China’s mismanagement of the outbreak impacted the rest of the world as its catastrophic neglect of economic freedom 40 years ago affected its own people. This time around, however, the international community pressured China to respond, demonstrating that the effects of global integration can be two-directional.

Looking ahead: averting an HIV/AIDS epidemic

China’s handling of the 1958–1961 famine and the SARS epidemic points to a few key lessons that may help China, and the global community, address future public health threats, particularly the emergence of HIV/AIDS in China. In 2003, an estimated 840 000 individuals in China were living with HIV/AIDS, 80 000 of whom had AIDS.³⁷

First, while the SARS epidemic exemplified the most authoritarian aspects of the Chinese political system (initial cover-up of the epidemic and massive firing and jailing of health officials), the experience has led to higher standards of public accountability. For example, the Chinese Ministry of Health has drafted regulations to hold accountable government officials who cover-up HIV/AIDS.³⁸ To the extent that China can codify (in law), enforce, and apply these regulations to those who have or will cover up the AIDS epidemic, it will have learned its lessons from SARS and the past famine.

Second, China’s handling of SARS emphasized that its public-health practices and policies affect the entire world and therefore provide the rest of the world with a vested interest in cooperating internationally to ensure global health.³⁹ A recent report on HIV/AIDS, for example, argued that the US should significantly increase its bilateral and multilateral ‘engagement’ with China to pre-empt a generalized epidemic that would have catastrophic global consequences.⁴⁰ Indeed, the SARS episode in particular demonstrated weaknesses in ‘China’s system for monitoring and responding to infectious disease.‘⁴¹ This has raised global concerns about the ability of the Chinese public health system to monitor emerging diseases.^40,41 Applying this lesson to the case of HIV/AIDS means that China’s public health practices are more vulnerable to public criticism. In order to obtain funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria, for example, the Chinese government was forced to publicize the spread of HIV through unsafe blood collection centres in a number of provinces.⁴² This public exposure could ultimately lead to impartial investigation of local and state authorities’ involvement in the collection and transmission of HIV-contaminated blood by, for example, the United Nations (UNAIDS or WHO). The Global Fund application also shed light on how the stigma surrounding HIV/AIDS in China has significantly hampered the country’s social and political response to the epidemic.⁴² This could lead to more rapid progress in protecting the rights of, and eliminating prejudice and discrimination practices against,⁴³ people affected by HIV/ AIDS.

Third, the SARS and famine case studies demonstrate the importance of sharing and accessing information, which can be essential for preventing and treating disease. Both tragedies tested the Chinese governments’ lack of toleration of public discussion and debate on public health subjects, and the mistake of hiding public health failures. In light of these events, the government has learned to treat HIV/AIDS as a major and genuine public health concern that requires a serious, coordinated response. A recent report on HIV/AIDS in China recommended media and educational campaigns, especially aimed at youth and China’s migrant population,⁴⁰ and a focus on informed, comprehensive approaches to prevention and treatment.⁴⁰

A fourth lesson lies in the deleterious social impact of violations in individual rights to freedom of assembly, association, and expression. The ability to exercise these rights enables citizens to organize interest groups to advocate for rights, respect, and resources. These rights, coupled with the ability to have free and full access to (and to share) information creates conditions under which effective advocacy can take place. Experience with the HIV/AIDS epidemic in the US demonstrates, for example, the power of advocacy groups (people living with HIV/AIDS in particular) in obtaining rights, resources, and greater dignity. Grassroots organizing by members of civil society (grassroots NGOs, for example) can have a positive effect on individuals’ health by improving access to, and the quality of, health care and residential services for people living with HIV/AIDS. Such assistance is critically needed in the fight against HIV/AIDS in China, especially in the delivery of public health services to poor, rural populations involving both Chinese and foreign NGOs.⁴⁰

A final key lesson from SARS and the 1958–1961 famine rests in the absolutely essential role of free, uncensored information, including the ability to voice complaints and opposition to government practices and policies and to shed light on corruption. The SARS-famine case studies highlight the Chinese government’s history of censorship and restrictions on freedom of the press. To combat HIV/AIDS and prevent it from becoming a full-scale epidemic, the Chinese government must permit both domestic and foreign journalists to report on the disease without any restrictions. Early indications suggest that the government is taking steps to address these restrictions better.

Conclusion

Democratic institutions and practices can affect human development in multiple ways, including population health and well-being. The absence of democracy, in particular, can have deleterious affects on health, as the 1958–1961 Chinese famine and the 2003 SARS outbreak demonstrate. These case studies highlight factors that are essential for preventing a full-scale HIV/AIDS epidemic in China: new and better standards of public accountability; an international imperative to cooperate globally to ensure health; freely available information, especially about disease prevention, control, and treatment; protection of individual rights and freedom of assembly, association and expression; and the ability to voice complaints and opposition. By instituting these rights in a timely fashion, China may be able to contain the HIV/AIDS epidemic before it loses millions of its citizens to yet another public health tragedy.