Political And Economic Determinants of Population Health and Well-Being:

Controversies and Developments

Vincente Navarro, Caries Muntaner, Vincente Navarro, Caries Muntaner

• Publisher: Routledge
• Year: 2020
• Print ISBN:
  9780895032782
• eBook ISBN:
  9781351863933
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

The field of social inequalities in health continues its vigorous growth in the early years of the 21st century. This volume, following in the footsteps of Vicente Navarro's edited collection The Political Economy of Social Inequalities, is a compilation of recent contributions to the areas of social epidemiology, health disparities, health economics, and health services research. The overarching theme is to describe and explain the evergrowing health inequalities across social class, race, and gender, as well as neighborhood, city, region, country, and continent. The approach of this book is distinctly multi-, trans-, and interdisciplinary: the fields of public health, population health, epidemiology, economics, sociology, political science, philosophy, medicine, and history are all represented here.

PART I

Social Policy

The Significance of Major Public Health Intervention

Social policy continues to capture the interest of public health scholars. Some of us may regard this as the key area of public health, the most upstream and macro, the area with the greatest potential to shape a society’s standards of living and determinants of population health. In Part I we begin with Vicente Navarro’s critique of Nobel laureate (in economics) Amartya Sen’s Development As Freedom. Progressive scholars were enthusiastic about this book, as it seemed to herald a departure from neoclassical economics. Navarro suggests that Sen’s work, while representing a major break with the dominant neoliberal position reproduced in most national and international development agencies, is insufficient to explain the key relationship between freedom and development. Thus, the absence of an analysis of the power relations that cause and reproduce underdevelopment through national and international political institutions leaves Sen’s work wanting. Navarro shows how Sen’s interpretation of events and the conclusions derived from them (such as an explanation for famine in Bangladesh) are insufficient. He also critically analyzes the U.N. Development Program reports, which, while documenting the nature and consequences of underdevelopment, barely touch on the political context in which underdevelopment occurs. Amartya Sen himself is the next contributor (Chapter 2), with a discussion of the relationship between high fertility rates and the low decisional power—indeed subjugation—of women.

Four chapters on economic inequality and social policy follow. Three of them—by Bo Burström and colleagues; Olli Kangas; and Timothy Smeeding and Peter Gottschalk—deal with cross-national comparisons; while the fourth, by Robert Chernomas, tackles the U.S. economy. Burström and coauthors, in a comparative study of British and Swedish labor markets (Chapter 3), test two opposing hypotheses: (1) that the increasingly flexible, deregulated labor market in Britain would result in an increased number of new jobs and thus better employment opportunities for unskilled workers, including those with chronic illness; (2) that the more regulated labor market in Sweden, with the associated health and social policies, would provide greater opportunities for jobs and job security for workers with chronic illness. The analysis of data on men from the British General Household Survey and the Swedish Survey of Living Conditions, 1979–1995, shows that employment rates are higher and rates of unemployment and economic inactivity are lower in Sweden than in Britain, and that differences in these rates across social class and between those with and without chronic illness are smaller in Sweden. The results support the hypothesis that active labor market policies and employment protection may increase the opportunities for people with chronic illness to remain in work.

Kangas tests the “trickle-down” theory, according to which wider income differences are good for economic growth, growth is good for the poor, and therefore widening income disparities benefit the poor (Chapter 4). His study presents a preliminary refutation of this theory, with income data for 21 countries obtained from the Luxembourg Income Study for the period 1985–95. The results do not show clear associations between inequality and economic prosperity. The wider the inequality, the worse is the absolute income of the poor. In this respect the theory is falsified. However, Kangas sees some beneficial effects of economic growth for the poor under capitalism: the absolute income level of the poor is dependent on what is happening in the national economy, while the incidence and depth of poverty in advanced countries are not so much associated with economic factors as a result of national social policy programs.

Smeeding and Gottschalk add to the cross-national analysis of income distribution (Chapter 5). A secular growth of income inequality took place over the last two decades of the 20th century, affecting almost every rich nation; this growth was matched by a growth in comparable household income inequality data, which made possible cross-national comparisons of income distribution. While finding clear patterns of disposable-income inequality differences in both level and trend, the authors argue that we are still a long way from explaining why these differences came about, whether they will continue to grow or stabilize, and what the social consequences of these changes might be.

Next, Chernomas describes how U.S. capitalism emerged from its crisis in the 1990s (Chapter 6). Capitalism entered an economic crisis in the late 1960s due to a fall in the rate of profit. With falling profits, corporations were compelled to find means of reducing costs by lowering wages and taxes and/or raising productivity. Attacks on the welfare state (in the form of the war on deficits and debts), unions, and government in general resulted in falling wages, longer hours of work, and increased poverty. Only in 1997, despite years of exaggeration about its macroeconomic recovery, did the United States finally have a true boom year—like something from the Golden Age of the 1950s or early 1960s: GDP, investment, productivity, employment, and even wages grew. Chernomas shows that this tentative recovery was accomplished in part by the state and corporate sectors’ ability to generate inequality over the last quarter of the 20th century—and shows how these macroeconomic policies changed the context for health and the health sector.

These six chapters provide convincing arguments on the importance of political choices at different levels of economic development, even during periods of slow growth. That is, they challenge economic determinism in social policy and for the most part point to social democratic policies as the means to reverse the negative impact of growing economic inequality. Interestingly, Chernomas seems to adopt a more critical perspective by pointing to the incompatibility between economic equality and capitalist growth.

CHAPTER 1

DEVELOPMENT AND QUALITY OF LIFE: A CRITIQUE OF AMARTYA SEN’S DEVELOPMENT AS FREEDOM

Vicente Navarro

WHAT IS THE GOAL OF DEVELOPMENT?

Thank you so much for inviting me to discuss Amartya Sen’s Development As Freedom (1). As a researcher who has worked for many years on the relationship between development and well being, I read this book with great pleasure. It centers on some of the issues I have been working on most of my life. The pleasure of reading the book was accompanied by the enjoyment of being exposed to a very well-thought-out argument that goes against the major position upheld by some of the most influential and powerful institutions working on development today. Indeed, Sen’s main objective is to dismantle the widely held position, constantly reproduced by the World Bank, the International Monetary Fund, the U.S. White House, the U.S. State Department, the U.S. Agency for International Development, and many other international and U.S. agencies, that the best way for a country to develop is to increase its rate of economic growth. I am aware of the growing differences among these institutions on the question of how development policies should be realized. I am also particularly aware of the growing distance between the World Bank and the International Monetary Fund on the means of achieving development; but these two institutions share the basic assumption that, in a fast-growing economy, whatever is produced at the top trickles down to all members of society, improving the lot of the majority of a country’s people. This position, which has reached the level of dogma, is what Amartya Sen calls—accurately, I believe—“conventional wisdom among the economic developmentalists” (1, p. 6).

I should indicate right away that this conventional wisdom had its share of critics from its very beginning, I being one of them. Actually, the first investigation I carried out in my academic career, back in the 1960s, was on the impact of what was then called the “economic miracle” of Brazil on the quality of life of that country’s people (2). As you may recall, the economic literature on development was full of articles highly laudatory of the Brazilian economy during the period 1968–1981, when that country had a very high rate of economic growth. The Brazilian economy seemed to be doing very well indeed—but what about the Brazilian people? The data I studied and published showed that while the economy was indeed doing very well, the people were not doing so well. In fact, infant mortality was growing rather than declining, as one would have expected if economic growth were benefiting all Brazilians. The infant mortality increased quite dramatically during that period, from 70 infant deaths per 1,000 live births at the beginning of the “miracle” to 92 per 1,000 at the end. That increase could not be explained by improvements in the system of collecting vital statistics in Brazil. I checked on this possibility; no major changes had occurred on that front. The reason for the spectacular increase in infant mortality had to be sought elsewhere—that is, in the general deterioration in the standard of living (as measured by available disposable income) of the majority o...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgments
• Introduction: Toward an Integrated Political, Economic, and Cultural Understanding of Health Inequalities
• Part I Social Policy
• Part II Globalization
• Part III Health Policy
• Part IV Healthcare
• Part V Occupational Health and Labor Unions
• Part VI Social Capital versus Class, Gender, and Race
• Part VII Ideology, Theory, and Research Policy
• Conclusion: Political, Economic, and Cultural Determinants of Population Health—A Research Agenda
• Index