Health care uses up scarce resources. Economics is concerned with making better choices in the use of scarce resources. Since health care and education are 'Income Elastic'- i.e. demand for both rises as productivity, and hence income, rises.
It may be that British Doctors were unaware of these facts which is why Lancet asked Amartya Sen to write about
Economics and health
some 25 years ago.
There is a gross story, but there are also some finer ones.
Nope. There is only one story. Medicine costs money. Those who earn more can be sure of getting more. End of.
The glaring connection between economic prosperity and good health is one of strong positive association.
No. There is a causal connection between having more money and being able to spend more on Health Care. There is none between being rich and being healthy. This is why kids, who have no money, are likely to be healthier and have higher life expectancy than very elderly, debauched, billionaires.
People of richer countries typically suffer less from diseases of one kind or another,
No. They suffer less from preventable or curable diseases because they can pay for more healthcare. They may have higher mortality for currently non-curable or non-preventable diseases if they have an ageing population with a sedentary lifestyle and health conditions related to affluence.
and live longer.
Unless they take a lot of drugs and enjoy shooting each other.
Richer people in the same country also typically have fewer illnesses and live longer.
See above.
Economic prosperity can thus be seen to be a good way of living better and living longer.
Because prosperity means 'living better'. You can certainly spend money on increasing your expected longevity.
As we move from one millennium to another, that gross story can indeed be a good starting point for analysis.
No. It is the last word on the subject. If a country raises productivity it can have more of all 'normal' goods and services including Health, Education, Policing, Transfers to the indigent, Environmental clean up, etc. etc. But everybody, except Sen, already knows this.
But it would be a mistake to take this to be the main wisdom to emerge from empirical studies on the relation between economic prosperity and good health.
Those 'empirical studies' are junk social science. This is not to say that ordinary people with lived experience of Healthcare can't figure out ways to make things work better. That's 'wisdom'. They don't teach it at Grad Skool.
Let me begin with discussing a statistical connection. Consider the important statistical analysis presented by Sudhir Anand and Martin Ravallion on inter-country comparisons between less-developed countries.
They asked the question 'Should development priorities shift toward the provision of public services in poor countries, even if such a shift is at the expense of income growth?' 25 years later we know the answer. Fuck provision of public services. They will turn to shit when the country goes off a fiscal cliff. Focus on income growth based on raising productivity preferably by climbing a value chain and participating in global markets. People are happy to pay for more healthcare and education as their income rises.
They found that life expectancy does indeed have a significantly positive correlation with gross national product (GNP) per head,
It enough to point out that Puerto Rico has higher life expectancy than the US to show that there is no causal link here. It is likely that some affluent countries would have lower life expectancy than some poor countries if the Pharmaceutical industry didn't have such a strong incentive to keep coming up with cures for 'diseases of affluence'.
but that the former also links closely with the incomes specifically of the poor,
Not if they are not counted in the figures. In some countries 'life expectancy' is a guess or is massaged by the authorities. In others, it is something actuaries can rely upon.
and with public expenditure particularly in health care.
No shit, Sherlock! Health-care costs money and getting it is closely linked to spending money on it. What Sen doesn't say is that poor countries don't have much money for public expenditure of any type. If they decide to first concentrate on health, education, transfers, etc, rather than income generation, then the very quickly run out of money and you have abandoned schools and hospitals and a complete collapse of transfers. Smart people have run away and productivity stagnates or falls because of lack of investment and crumbling infrastructure.
Furthermore, once these two variables are included on their own in the statistical exercise, no extra explanation can be obtained by also including the GNP per head as an additional explanatory variable.
Because in 'less developed countries' most people are poor. Still, GNP per head is important. If it is much higher than the poverty level, then there is 'fiscal headroom'- i.e. public expenditure on health, education may be sustainable. Otherwise, one way or another, club goods will be rationed. Generally, this means, the poorest go to the wall.
Indeed, with poverty and public-health expenditure as variables on their own, the statistical connection between GNP per head and life expectancy seems to vanish altogether.
Only if the Statistician is as stupid as shit. It should be remembered, Sen didn't actually know any econometrics. If GNP per capita falls below the subsistence level, then either people have to emigrate, rely on charity, or prepare to die in great numbers.
What does this result show?
Economists are stupid. Stop funding them.
Not that GNP per head or a country's average economic opulence is irrelevant to longevity,
It is all that matters. A country which has no money can't spend on shit. The question is, what should poor countries focus on? Well, if they can't compete globally, maybe they should educate their kids and rely on remittances while making the place a nice one to retire to. This is the Kerala model. Cuba exports pharma and doctors and also spends a lot on education. But, its economy is in dire straits.
but that the influence of economic opulence on longevity may work mostly through the relation between opulence and two crucial policy variables (poverty removal, public health-care).
In other words, if you have the money to pay pay people to buy stuff and also provide them free health-care, then that's what you can do. But should you? Probably not. Spend on what can raise your income in the future. Your country is simply too poor to imitate the policies of affluent Welfare States. Obviously, you needn't actually admit that. Tell lies same as other politicians do.
Much would thus depend on how the fruits of economic growth are used.
Did you know that if you gave a lot of your fruits to very poor people then they would nice fruit to eat? Oh. You did. In that case you don't need a Nobel Prize in Econ to convince yourself you understand the subject. Still, the question remains, should you give away all your fruit to the poor or should you sell as much as you can at a high price and then invest in other income generating schemes? The answer is, do the latter otherwise your country will remain a shithole.
This helps to explain why some economies (such as South Korea and Taiwan,
both of which faced a military threat and therefore had conscription. They needed to do export led growth because the US could pull the plug on them anytime. Look at Ukraine now. Trump says 'Since I pay the piper, I call the tune. I will decide everything with my pal Putin. Zelenskyy can go fuck himself.'
among others in east and southeast Asia) have been able to raise life expectancy so rapidly through economic growth,
Life expectancy would have risen away because hostilities hand ended and much better, cheaper, medicines were becoming available.
whereas others with a similar record in fast economic growth (such as Brazil)
but Brazil had free, universal, care since 1990!
have not achieved correspondingly rapid longevity expansion.
Nonsense! Brazil converged quite rapidly to the US rate till a few years ago. It is likely that Korean, Japanese and Taiwanese diet is more healthy than that of the US which is why such countries overtook the US.
There is a further issue in not taking the gross account to be the final one.
That issue is nonsense.
Even though for all the countries put together, the richer ones do indeed show greater achievement in life expectancy, the outliers may tell us something quite important about public policy.
Doctors know life expectancy went up because of better, cheaper, drugs. There was little point having much in the way of public health policy when health-care was shit. Sen doesn't understand this.
Indeed, we can get a “sub-story” in separating out some countries with very different extents of activism in public health-care, and notice that the ones more committed to public healthcare do very much better than the ones not so committed.
Sen comes from India. He should know that 'commitment to public health care' quickly disappears if it turns out to be shit. Kerala is a nice place to live and Doctors and nurses aren't incessantly kidnapped or raped. Anyway, it could export Doctors and Nurses and also benefitted from remittances. Tamil Nadu was more pro growth and might now be ahead in certain respects. West Bengal, sadly, is now a place where Doctors are beaten or raped in the very hospitals they work in.
Study the GNP per head and life expectancy at birth of six countries (China,
which got rid of free universal (but 'barefoot') medical care in the Eighties. Provision increased and improved in quality as Income grew
Sri Lanka,
has had free universal healthcare since the 1930s
Namibia, Brazil, South Africa, Gabon
South Africa and Gabon had a big AIDS problem
) and Kerala, a sizeable state in India with 30 million people—
where fifteen percent of the workforce is labouring abroad to send home remittances. This is not true of the other countries. Anyway, China- which focussed on Income growth, has outperformed all the other countries. It had quarter the per capita income of Brazil in 2000 (Kerala has now reached that level) but it is now twenty percent richer. Incidentally, it still spends a smaller portion of its GDP on healthcare than Brazil.
large enough to count as a country, but with a much better record of public education and health care than the Indian average.
Tamil Nadu, which went for income generation, has pretty much closed the gap. Still, it is Nagaland which comes out top. I suppose, giving up head-hunting dramatically impacts longevity.
Despite their very low levels of income, the people of Kerala, China, and Sri Lanka enjoy much longer life expectancy
no. Once you take into account risk factors, life expectancy isn't much greater
than do the much richer populations of Brazil, South Africa, Namibia, and Gabon (figure).
No. The very poor in Kerala did a bit better than the very poor in some other Indian states. That's all we can say. It is pointless comparing Kerala to places with different risk factors. Kerala did spend more on health and education relative to per capita income. But, a lot of that had to do with remittances. There was a culture of doing arduous labour abroad so as to pay the family's medical bills and school fees. But Kerala would be much better off now if it had encouraged the growth of industry. In other words, the people of Kerala now realize that 'the Kerala model' was stupid.
Health and longevity does respond to greater care,
which is only given because more money is being spent
despite the barrier of low income.
I could buy a superyacht, despite the barrier of low income, if the Government gave me a billion dollars. This
The fact that health care, basic education, and other crucial components of social opportunity are highly labour-intensive activities make them affordable even in poorer economies, where labour is also cheaper.
Sadly, they may be wholly shit. Illiterate teachers and Doctors who don't know Medicine may be very cheap and you may be able to hire lots of them, but they are also useless.
A related lesson emerges also from the observed fact that in the USA, African Americans as a group—men and women—have a lower chance of reaching advanced age than do men and women born in the immensely poorer economy of the Indian state of Kerala, and (in the case specifically of men) than do the Chinese as well.
In 2000, African Americans had higher life-expectancy than did people in Kerala. However, they were much more likely to die of affluence related diseases. Sen was simply wrong to keep banging on about Kerala. Its people worked hard but did not get a commensurate reward because income-generating activities were not permitted to burgeon. This is changing. Kerala's tax base is collapsing because more and more of those who work abroad now choose to settle there as well. Their mansions back home are empty and no tax can be collected from them.
The shorter lives
this has shrunk from about 7 to about 3 years.
of African Americans relate not to their low incomes
yes it does. Rich African Americans got the best medical care in the world and lived to a ripe old age.
(they are, in fact, very much richer in per-capita income than the Chinese or the Keralite), but to the lack of guaranteed health care (with big gaps in medical insurance), blighted educational arrangements, and other problems of social malaise and disruption.
caused by low incomes. Sen truly is as stupid as shit.
Indeed, the average African American man in New York, or San Francisco, or the District of Columbia has a lower life expectancy than does even the average man in India or Pakistan.
The average non-drug taking, non-gun toting, African American man had higher life expectancy than similar people in India or Pakistan even with some level of affluence related disease.
So what do we conclude?
Sen has shit for brains.
The gross story stands, but it needs to be supplemented by the finer aspects of the relation between economics and health.
There are no finer details. There are only stupid lies. Ceteris paribus, more spending on health-care (howsoever it is done) correlates with better outcomes. But spending requires income. Thus, the first priority must be raising income rather than putting the cart before the horse and spending first and hoping the income will turn up later on.
Economic prosperity certainly helps, taking the rough with the smooth.
Health care uses up scarce resources. Economic prosperity provides those resources. There is no rough. There is no smooth. There is simply this fact which is known to all.
It is, however, up to us to build more smoothness in the rough terrain.
Sen didn't build shit. He was simply wrong to say that poor countries should first focus on health and education rather than income generation. Every developed country took a hard-hearted route to prosperity. Once Incomes rose, more was spent on 'normal' goods- like Health, Education, etc. There could be economies of scope and scale in having public provision of this. For poor countries, raise the productivity of those already making a living in these fields and let competition raise standards. For the affluent, the market will provide and as Income rises, it will be profitable to extend this. At a later point you can have an integrated National Health System. But the thing can't be created and sustained if per capita Income isn't high enough.
The fact that public policy makes a difference
if there is sufficient tax revenue- not otherwise
is of interest not just for social activism,
i.e. pretending there is a magic money tree which the Government is meanly refusing to let poor people have access to
but also for good economic analysis.
Something Sen was incapable of.
We reap as we sow.
Sen sowed nothing and reaped nothing. It isn't the case that saying 'be virtuous' is itself virtuous nor that telling other people to give money to charity means that you are yourself a great philanthropist. Still, Sen got paid to talk bollocks and, with commendable diligence, that is precisely what he did and, 25 years later, still does.
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