Editor’s Note: Tom Bollyky is the director of the Global Health program at the Council on Foreign Relations and author of “Plagues and the Paradox of Progress: Why the World is Getting Healthier in Worrisome Ways.” Follow him on Twitter at @TomBollyky. Tara Templin is a health policy Ph.D. student at Stanford University. The views expressed here are those of the authors; view more opinion on CNN.
Thomas Jefferson and one of his co-signers of the Declaration of Independence, physician Benjamin Rush, once argued that sick political systems and despotism produce sick people and disease. It may seem, however, like history has abounded with counterexamples.
Cuba and China have long been famous for providing good health care at low cost. The biggest gains against infectious diseases and child mortality in recent years were achieved in nations like Ethiopia and Myanmar, where controversies surrounding rigged elections have dominated the political scene. Meanwhile, with all the political turmoil in the United States, United Kingdom and Europe, the case for democracy worldwide has arguably never seemed dimmer.
But a new research study suggests that while democracy may be messy, it is still better than the alternatives for public health challenges now confronting most nations.
Together with colleagues from the Institute for Health Metrics and Evaluation and Bilkent University, we published a study in The Lancet that is the first comprehensive assessment of the links between democracy, adult health and disease-specific mortality in 170 nations over 46 years, 1970 to 2016.
The findings are dramatic.
Adult life expectancy at age 15 was 3% higher on average in countries 10 years after their transition to democracy compared to nations that remained autocratic. A nation’s democratic experience – a measure of how democratic a country has been and for how long – matters more than its gross domestic product in the reductions in deaths in a country from cardiovascular diseases, transportation injuries, cancers and other noncommunicable diseases. Between 1995 and 2015, we estimate that increases in democratic experience averted 16 million deaths globally from cardiovascular diseases alone.
Why does democracy matter so much for the chronic diseases that disproportionately affect adults? Anyone who has suffered from heart disease or cancer, or had a loved one who has, knows all too well that the treatment of these diseases is expensive and occurs over time.
Much of that chronic care is delivered in surgical facilities and hospital beds by trained doctors and nurses. In contrast, targeted vaccination campaigns, anti-malaria bed nets and community health worker programs have succeeded in reducing child deaths even in countries with dysfunctional governments and limited infrastructure, allowing some nondemocratic nations to make dramatic progress in recent years.
Our findings show that governments that are regularly accountable to voters in free and fair elections are more likely to make that investment in health care personnel and infrastructure. They are also less likely to withhold health and welfare services from opposition groups. Indeed, our study reveals that while becoming more democratic does not necessarily make nations wealthier, it does lead to the government spending more on health and fewer deaths from cardiovascular disease.
In the past, global health initiatives were strictly apolitical. Many of the largest recipients of foreign health aid rank among the least democratic nations of the world. But our research results suggest that it is not sustainable to treat a political system and the health of the people governed by it as unrelated.
Deaths and disability from breast and cervical cancers, stroke and other noncommunicable diseases are surging in many poorer nations, and will likely continue to grow. In 2015, these noncommunicable diseases already killed more than 8 million people under the age of 60 in lower-income nations. By 2040, noncommunicable diseases will affect roughly the same share of the populations in Myanmar, Bangladesh and Ethiopia as in the United States, except that these chronic diseases will arise in much younger people in these poorer nations with far worse health outcomes.
To grapple with the fast rise in noncommunicable diseases, the United Nations and the World Health Organization have proposed new goals on universal health care, tobacco taxes and the promotion of better diets. These objectives are no less political in other nations than they are in the United States. Generating public support for sustainable health institution improvements can only occur in nations with an open and accountable government, a free media and a vibrant civil society.
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So must international health workers now do double duty, vaccinating children while registering their parents to vote, too? Not necessarily, but it does require ensuring global health investments are paired with greater international support for democracy and governance, which is at its lowest ebb in decades.
Our research suggests that Jefferson and Rush have been proved right: Healthy populations can only be sustained with healthy and accountable political systems. Two centuries later, global health programs still have more work to do to put that insight into practice.