Practice Exam Questions Flashcards
The US has lower life expectancy than other high-income countries. What explains the US health disadvantage compared to other affluent countries?
“[Robert] Anderson [chief of mortality statistics with the National Center for Health Statistics] said the latest data suggest this mortality trend is heavily influenced by the ongoing drug epidemic and a rising rate of suicides nationwide”
House, J. S. et al., 2010. ‘The Health Effects of Social and Economic Policy: The Promise and
Challenge for Research and Policy’
o “…despite the marked growth in spending over the past fifty years, the U.S. has fallen from being amongst the top in life expectancy and infant mortality to ranking at or near the bottom among developed nations. Of the thirty nations in the OECD, only Mexico, Turkey, and three former Soviet bloc countries consistently rank below the U.S. on such indicators”
o “Most political and policy analysis related to health in the United States focuses on medical-care and insurance. Little attention is paid to levels of population health beyond the worry that spending constraints may adversely affect it. The concentration of policy discussion on medical services however, ignores historical facts about the causes of major changes in the overall health of populations”
o “The idea that a country could achieve better population health without explicitly increasing health care spending may seem paradoxical, but only if we assume that health care is the major determinant of health. As dramatic and consequential as medical care is for individual cases, much evidence suggests that such care is not, and probably never has been, the major determinant of overall levels of population health”
o “This evidence is consistent with data suggesting a low to near-zero correlation between health care expenditures and levels of population health across wealthier OECD nations, as well as with data that show declining rates of return to health from growing health care expenditures over time in the United States (Cutler, Rosen, and Vijan, 2006)”
o “RATHER, economic, social, psychological, behavioral and environmental factors are more likely the major determinants of population health”
o “John Bunker, Howard Frazier, and Frederick Mosteller (1994) have estimated that only about five years of the almost thirty-year increase in United States life expectancy over the twentieth century were due to preventive or therapeutic medical practice”
o “The exact nonmedical factors responsible for the great historical rise in life expectancy [between the mid-eighteenth and mid-nineteenth centuries, and accelerating in the first half of the twentieth century] are impossible to identify retrospectively, but general socioeconomic development—most notably improvements in nutrition, sanitation, housing and clothing, and general conditions of life, certainly played a central role”
o “Concurrently, the rise of chronic diseases produced a major shift in the epidemiologic conception of and search for their causes—a shift from identifying a single necessary, proximate causal agent to identifying multiple contingent causal forces or risk factors. None of these risk factors are necessary to produce disease, but each interacts with others, increasing the likelihood of developing major chronic diseases and the pathogenic physiology underlying them (Kannel, 1971; Aronowitz, 1998)”
o “…a strand of research by Walter Cannon (1932), Hans Selye (1956) and others showed that perturbations in the relation between organisms and their psychosocial, as well as their physical, chemical, and biological environments led to physiological symptoms in the form of, for example, heightened heart rate or blood pressure. These are perhaps best known collectively under Selye’s rubric of stress. These symptoms in turn could lead to physical disease and even death”
o “This work led to burgeoning new fields of psychoneuroendocrinology and psychoneuroimmunology (Ader, Felten, and Cohen 1991) and showed how a broad range of socioeconomic and psychosocial factors could “get under the skin” and produce physical illness (Taylor, Repetti, and Seeman 1997)”
o “Though biological risk factors (i.e. blood pressure, cholesterol) were the central focus of attention initially, increasingly behaviors (such as tobacco use or a sedentary life-style), have also been identified as high risk factors for various chronic diseases”
o “Perhaps the most striking and important development in social epidemiology over the last quarter century has been the discovery (or rediscovery) of large, persistent and even increasing disparities in health by socioeconomic status and race-ethnicity (Marmot, Kogevinas, and Elston 1987; Pappas et al. 1993; Wilkinson 1996; Kaplan and Lynch 1997; House and Williams 2000)”
o “Not surprisingly, socioeconomic position shapes people’s experience of, and exposure to, almost all risk factors for poor health (Marmot, Bobak and Smith 1995; Lynch et al. 1996; House and Williams 2000)”
o “Current research on the psychosocial, biomedical, and environmental determinants of health has moved in two directions.
1) The more common approach might be referred to as ‘downstream,’ that is, seeking to understand the mechanisms through which psychosocial risk factors affect health. This approach tends to lead to a biomedical approach to mitigating the health impact of social or economic risk factors—for example, finding a pharmacological treatment for stress
2) An ‘upstream’ approach, on the other hand, seeks to understand the broader aspects of social life that shape exposure to such psychosocial or environmental risk factors. Many public policies strongly impact health because they strongly impact the socioeconomic, psychosocial, and/or environmental determinants of health”
o “The inherent difficulty in proving that a particular social or economic policy or program impacts health is complicated by competing approaches to determining causality.
1) One view holds that the only way to establish a causal relationship is through randomized experimentation, or a close approximation.
2) A different tradition derives its power from an accumulated body of evidence showing consistency of statistical association across a wide number of studies”
o “Both approaches [to determining causality] have value, and increased engagement and interchange between the two is crucial”
o “The case of cigarette smoking provides a fascinating example of how policies not specifically aimed at health can impact it. Originally U.S. policy addressing cigarettes had little or nothing to do with health, but much to do with agriculture and commerce. As smoking increased, likely due at least in part to these policies, evidence suggesting that the concurrent increase in chronic disease might be related to smoking began to mount. Though it took decades, causality was eventually determined. But even as consensus grew, many doubted that it was technically, politically or ethically feasible to reduce the consumption of cigarettes”
o “In the end, efforts outside the traditional realm of health—from taxation to restrictions on where and when people could advertise, buy, and use tobacco products—proved more feasible and cost-effective than medical attempts to somehow block the adverse effects of tobacco smoke”
o “One reason economic and social policy is less frequently employed as a tool for improved health is that while there is a well-established paradigm and a supportive institutional structure for basic biomedical research and its translation to health policy and practice, nothing approaching this exists for social or economic determinants of health”
o “Even when basic research provides strong evidence of the health impact of socio-economic factors, there is no infrastructure to systematically translate these findings into policy and practice. We need to foster the social and economic equivalent of clinical trials through the experimental introduction and evaluation of potential new policies and programs”
o “Though some well known—and highly regarded—social experiments have been conducted (the Negative
Income Tax and MDRC welfare-reform evaluations come to mind), they have typically been implemented with a focus on specific outcomes relative to the income maintenance and/or welfare-reform debate”
o “Six key policy areas with potentially sizable effects on health are addressed [in ‘Making Americans Healthier: Social and Economic Policy as Health Policy’]: education policy, income-support policy, civil-rights policy, macroeconomic and employment policy, welfare policy, and housing and neighborhood policy”
o “Just as we now routinely evaluate the environmental impact of programs and policies not explicitly environmental in nature (Irwin and Scali 2005), the United States must move toward models recently advocated and adopted in Canada, Sweden and the broader European Union that consistently consider evaluating the impact of all policy—not just health policy—on health outcomes (Raphael and Bryant 2006; Navarro 2007)”
According to Michael Marmot, ’we know what to do to make a difference’ to health inequalities (2015, p. 41). Discuss whether he is correct.
WHO definition of health inequalities:
o “Health inequalities are differences in health status or in the distribution of health resources between different population groups, arising from the social conditions in which people born, grow, live, work, and age”
Factors affecting health outcomes:
o Age, sex and hereditary factors (non-manipulable)
o Individual lifestyle factors
o Social and community networks
–> Agriculture and food production; Education; Work environment; Living and working conditions; Unemployment; Water and sanitation; Health care services; Housing
Would eradicating poverty also eradicate health inequalities?
‘Health and longevity are intimately related to [relative] position in the social hierarchy’ (Marmot, 2004)
o Relative position in the social hierarchy, rather than absolute wealth, is what matters in determining health inequalities
Kawachi et al. (1997). ‘Social Capital, Income Inequality,
and Mortality’
o The degree of income inequality in each state was estimated by the Robin Hood Index, which is equivalent to the proportion of aggregate income that must be redistributed from households above the mean and transferred to those below the mean in order to achieve perfect equality in the distribution of household incomes—the higher the Robin Hood Index, the more unequal the distribution of income
o US states that had high levels of social mistrust (i.e., high proportions of respondents who agreed that “most people would try to take advantage of you if they got the chance”) had higher age-adjusted rates of total mortality
o Lower levels of social trust were associated with higher rates of most major causes of death, including coronary heart disease, malignant neoplasms, cerebrovascular disease, unintentional injury, and infant mortality
o Adjusting for state variations in poverty resulted in some attenuation [reduction] of the regression coefficients; nevertheless, the coefficients for social trust remained highly statistically significant for total mortality, malignant neoplasms, infant mortality, and stroke; these coefficients were of borderline statistical significance for coronary heart disease mortality
o Only in the case of unintentional injury was there a substantial attenuation in the association between the social trust measure and mortality, suggesting a major role of poverty in explaining state variations in deaths from this cause
o The path analysis indicated that the primary effect of income inequality (as measured by the Robin Hood Index) on mortality is mediated by social capital (as measured by level of perceived fairness)…income inequality exerts a large indirect effect on overall mortality through the social capital variable…as income inequality increases, so does the level of social mistrust, which is in turn associated with increased mortality rates
House et al. (1988). ‘Social Relationships and Health’
o More socially isolated or less socially integrated individuals are less healthy, psychologically and physically, and more likely to die
o The first major work of empirical sociology found that less socially integrated people were more likely to commit suicide than the most integrated (Durkheim, 1897; 1951)
o In subsequent epidemiological research age-adjusted mortality rates from all causes of death are consistently higher among the unmarried than the married (Carter and Glick, 1970)
o Unmarried and socially isolated people have also manifested higher rates of tuberculosis (Holmes, 1956), accidents (Tillman and Hobbs, 1949), and psychiatric disorders such as schizophrenia (Faris, 1934)
o Question of causality: Does a lack of social relationships cause people to become ill or die? Or are unhealthy people less likely to establish and maintain social relationships?
o Above questions largely unanswerable until the 1980s for two reasons:
1. First, there was little theoretical basis for causal explanation
2. Second, evidence of the association between social relationships and health, especially in general human populations, was almost entirely retrospective or cross-sectional until the late 1970s
o Retrospective studies from death certificates or hospital records ascertained the nature of a person’s social relationships after they had become ill or died, and cross-sectional surveys of general populations determined whether people who reported ill health also reported a lower quality or quantity of relationships
o Such studies used statistical control of potential confounding variables to rule out third factors that might produce the association between social relationships and health, but they could do this only partially—they could not determine whether poor social relationships preceded or followed ill health
o The concept of “social support” was first used in mental health literature (Caplan, 1974), and was linked to physical health in separate seminal articles by physician-epidemiologists Cassel (1976) and Cobb (1976)
o Chronic diseases have increasingly replaced acute infectious diseases as the major causes of disability and death, at least in industrialized countries
a. Consequently, theories of disease etiology have shifted from ones in which a single factor caused a single disease, to ones in which multiple behavioral and environmental as well as biologic and genetic factors combine, often over extended periods, to produce any single disease, with a given factor often playing an etiologic role in multiple diseases
o The most compelling evidence of the causal significance of social relationships on health has come from the experimental studies of animals and humans and the prospective mortality studies…studies in which the measures of social relationships are merely the presence or absence of familiar other organisms, or relative frequency of contact with them, and which often do not distinguish between buffering and main effects
a. Thus, social relationships appear to have generally beneficial effects on health, not solely or even primarily attributable to their buffering effects, and there may be aspects of social relationships other than their supportive quality (i.e., their capacity to buffer/moderate the deleterious effects of stress or other health hazards) that account for these effects
Does education improve health through improving economic circumstances, through improving cognitive skills, or through some other mechanism?
The well-documented relationship between education and health outcomes operates through various pathways, including those of information and cognitive skills, family formation, and social networks
Education
o Cutler and Lleras-Muney (2010); Rosenzweig and Schulz (1981) propose that education serves to affect health-relevant behaviors such as drinking, smoking, dietary choices, and adherence to safety precautions, perhaps by directly teaching what is healthy, or by producing educated people who are better able to both obtain and critically evaluate health information, as is suggested by Kenkel (1991), Nayga (2000), and de Walque (2007)
Family formation o Chicoine (2012) investigates the relationship between women's education and fertility in the Kenyan context, finding that a policy change lengthening primary school by one year led to an increase in education, a delay in marriage, and reduced fertility beginning at the age of 20
Social networks
o Education informs the development and composition of our social networks, with implications for health that endure beyond the actual years of schooling
o Oreopoulos and Salvanes (2011) argue that schooling improves trust and social interaction, while also facilitating residence in healthier environments
Additional: Personal autonomy / stress
o Becker and Mulligan (1997); Fuchs (1982) hypothesize that education might improve health and health behaviors by positively affecting certain psychological predispositions, such as sense of control and time preferences
Still, it is important to note that even a consistently recognized correlation does not necessarily imply a causal link between education and health outcomes:
o There may be some confounding variable, such as an individual’s unobserved social and genetic background, that drives both educational attainment and health behaviors
o Reverse causation could also account for the observed correlation, with unhealthy people going on to obtain less education; in this instance, education would be inversely related to health
Education can be inversely related to health:
o Poor health → low levels of education
Other factors can drive the relationship between education and health:
o Race → Education → Health
- E.g.: African-Americans with the highest levels of educational attainment (16+ years) have worse health than other racial groups with the same level of education (Olshansky et al., 2012)
o Family background/genetics → Education → Health
- E.g.: Twin studies have provided some evidence that differences in education have no impact on health (Lundborg et al., 2016)
Health behaviors are not fully explained by differences in education and health (Cutler et al., 2011)
Education as a positional good—the value of education changes depending upon how many people within a society possess it
CONCLUSION: Expanding education does not always improve health (especially in HIC contexts)
Trade liberalisation can bring health benefits as well as health harms. What changes could be made to trade agreements or to trade organisations (such as the WTO) that would maximise the health benefits of trade?
Trade liberalisation in a nutshell:
o Trade liberalisation theoretically lowers prices and spreads growth;
o But its actual effects on health outcomes are unclear as it remakes the labour market and alters the goods and services within countries
Trade liberalization spreads technology and can make certain goods cheaper, such as food, potentially improving health. However, trade liberalization may create unemployment whilst spreading unhealthy commodities. As a result, the health effects of trade liberalization have been hotly debated (SYLLABUS)
Potential pathways from trade liberalisation to health outcomes: o Pharmaceutical patents o Harmonisation of standards o Negative goods o Distributional consequences
Four key factors that link trade policy to social determinants of health: (1) income, (2) inequality, (3) economic insecurity, and (4) unhealthy diets (Blouin et al., 2009; Cornia et al., 2008)
1.
Trade policy –> Material deprivation (INCOME and its distribution) –> Mortality shifts due to nutritional, infectious diseases –> Health outcomes
2.
Trade policy –> High level of social stratification and lack of social cohesion (income INEQUALITY –> Chronic stress, mortality changes in coronary heart diseases, cardiovascular diseases, and violent deaths –> Health outcomes
3.
Trade policy –> Acute psychosocial stress (ECONOMIC INSECURITY) –> Mortality changes in coronary heart diseases, cardiovascular diseases, and violent deaths –> Health outcomes
4.
Trade policy –> Unhealthy lifestyles (UNHEALTHY DIETS) –> Shifts in mortality due to chronic diseases –> Health outcomes
INCOME: Blouin et al., 2009 (‘Trade and social determinants of health’)
o Evidence shows a solid positive relation between a country’s wealth and its population’s health, defined in terms of increased life expectancy (Preston, 1975) and reduced child mortality (Prichett and Summers, 1996)
o Findings also suggest that the association is not linear, because income is more important for health in poor countries than in rich nations, where life expectancy is less sensitive to variations in income (Bloom and Canning, 2007)
o High income means enhanced capacity to access goods and services, which promotes health benefits such as clean water, nutritious food, adequate housing, sanitation, education, and quality health services
o Assignment of a specific weight to the causes is very difficult: “Although there is a strong case for the direct effect of income on health due to nutrition and health interventions becoming more affordable, it may be that income is also acting as a proxy for a wider measure of socioeconomic status and development” (Bloom and Canning, 2007)
o Irrespective of the mechanisms at work, if trade liberalisation has a clearly positive effect on income and material conditions, improvements in health outcomes should naturally follow
o Whether or not trade liberalisation increases aggregate income, e.g., a country’s gross domestic product (GDP), not everybody will gain from this new wealth
a. In view of the non-linear relation between income and health, to understand the effect of trade liberalisation on the income of poor households is especially important
Researchers generally agree that trade liberalisation alone is insufficient to boost the economy, and in several countries, liberalisation has not translated into economic expansion (World Bank, 2005)
o Complementary policies are needed to ensure that trade openness leads to a high level of growth
o Such initiatives include a stable macroeconomic environment, competitive exchange rate, solid fiscal policies, well functioning agricultural and labour markets, and physical infrastructure (port, roads, telecommunications) (Rodrik, 1999)
If we go beyond the aggregate effect (GDP growth) and look at the distributive outcomes of trade, evidence becomes even more complex and indirect (Winters et al., 2004)
o To clarify, we are referring here to a country reducing or removing its barriers to imports and foreign investment and subsequent outcomes on the poverty level of its own population—we are not describing the effect of industrial countries’ withdrawing their trade barriers on imports from developing countries, which researchers agree could reduce poverty, albeit modestly (Cline, 2004)
o Trade reforms create winners and losers: some sectors of the economy might not be able to compete with new imported goods whereas others get access to new markets and opportunities
o Moreover, individual incomes can alter because jobs can be created or lost and prices of and external demand for goods produced can rise or fall. Therefore, some losers from trade liberalisation might be poor households whose income will further fall (Winters, 2006)
o “Based on the data available from cross-country comparisons, it is hard to maintain the view that expanding external trade is, in general, a powerful force for poverty reduction in developing countries” (Ravallion, 2006)
a. Ravallion further stresses the importance of undertaking disaggregated analyses of the effects of trade reforms on households, to monitor poverty
b. Therefore, policymakers concerned about the effects of their trade reforms on poverty and health should check outcomes for different regions of the country, for urban versus rural households, and for other relevant groups (e.g., sex, types of rural households, age)
c. Such observation should be done with a view to design domestic economic and social initiatives that ensure that trade policy does not worsen the living conditions of poor households and does not lead others to fall into poverty
INCOME INEQUALITY: Blouin et al., 2009 (‘Trade and social determinants of health’)
An assumption behind trade liberalisation is that developing countries, which have an abundance of unskilled labourers, would gain from trade in products produced by unskilled labour. Further, the position of unskilled labour in the labour market would be enhanced vis-à-vis other factors of production, leading to a fall in the skills premium and hence reductions in inequality
o HOWEVER, in many cases, the conditions under which these theories are valid do not apply—e.g., no full employment, different technologies for production (Ocampo and Taylor, 1998)
o As a result, trade liberalisation has actually led to widening wage differentials, with a substantial rise in relative rewards for skilled labour (Hoekman and Winters, 2005) whereas unskilled workers remain engaged in informal activities rather than being in regular employment (ILO, 2004)
Research done in many poor countries shows that tariff reductions are associated with greater inter-occupational wage inequality, favouring skilled over unskilled labour (Milanovic and Squire, 2005)
o This view is supported by growing data of detailed case studies, which indicate that increased trade openness contributes to wage disparities in countries such as Brazil (Pavcnik, 2002), Mexico (Robertson, 2000), Chile (Beyer, 1999), and Colombia (Attanasio et al., 2002)
By contrast with Latin America, little or no rise in inequality between unskilled and skilled labour took place in most Asian countries, at least before 1997 (Cornia, 2004), but in most reviews published since this time, a growing wage differential has been noted in this region
o Some analysts attribute this finding to greater and more egalitarian access to education in Asia versus Latin America—i.e., Latin America has many highly educated university graduates, but inequality in educational attainment is very large
o Data of a study showed that “increased international trade transforms […] educational inequalities into wage inequalities by favouring skilled over unskilled labour” (Mamoon and Murshed, 2005)
ECONOMIC INSECURITY: Blouin et al., 2009 (‘Trade and social determinants of health’)
Trade liberalisation is usually accompanied by enhanced openness to foreign capital and liberalisation of financial markets and services. However, the combination of trade and financial liberalisation is often associated with heightened economic insecurity (Rodrik, 1997) (though this view is challenged by Bourguignon and colleagues working on East Asia)
o Examples of economic instabilities include financial crises, currency devaluations, and rapid changes in labour markets and employment (Cornia, 2001)
o During trade reforms, job creation is generally accompanied by employment losses because labour moves from one sector or industry to another
a. This process—known as churning—needs social safety nets and smooth employment transition mechanisms to lessen material and psychological stress to workers and their families
b. Findings of a study by the International Labour Organization (ILO), of manufacturing jobs in 77 countries, showed that high levels of international trade in a national economy were associated with increased movement of workers between sectors
c. Intersectoral movement makes finding new employment difficult and costly for displaced workers, because moving into a different sector usually needs a change in skillset (Torres, 2001)
DIET AND NUTRITION: Blouin et al., 2009 (‘Trade and social determinants of health’)
Trade liberalisation is one variable that can lead to alterations in diet and nutrition
o An increase in food prices has been blamed partly on rapid urbanisation and rising wages in some middle-income countries, and these factors are changing demand for particular diets (UN, 2008)
o Modifications in food supply have also altered radically the food environment and choices that consumers make (Kennedy et al., 2004)
o Reductions in prices of unhealthy foods—i.e., calorie-rich, nutrient-poor, high in saturated fats and salt—compared with healthy foods, increased desirability and availability of unhealthy foods, worsening asymmetry between consumers and suppliers of foodstuffs, and growing urbanisation and changes in lifestyle are all possible means by which trade liberalisation could affect popular diets, especially those of poor populations
a. Several detailed country case studies have been done in which links between trade liberalisation, changes in availability and pricing of oil, and processed foods (and hence diets) have been described (Popkin, 2006) b. This association is perhaps mostly starkly indicated by the experience of some Pacific island populations: researchers on several studies have noted displacement of traditional diets with high-fat imported foodstuffs and a concomitant increase in obesity rates and chronic diseases (Evans et al., 2001) c. Poor households are most sensitive to food price changes and, thus, are likely to change their diet accordingly (Guo et al., 1999)
o Trade liberalisation can affect availability of certain foods by removal of barriers to foreign investment in food distribution
a. Evidence suggests penetration of supermarkets into various food retail markets of southern Africa, Latin America, and China (Reardon et al., 2003) b. Transformation of food retail has facilitated a pronounced shift to consumption of processed food (Nestle and Jacobson, 2000) c. Trade liberalisation can also enable foreign investment in other types of food retail; multinational fast-food outlets have made substantial investments in middle-income countries (Chopra, 2002)
o Availability of processed food has risen in developing countries after foreign direct investment by multinational food companies
a. For example, US investment in foreign food-processing companies grew from US$9000 million in 1980 to US$36 000 million in 2000, with sales increasing from US$39 200 million in 1982 to US$150 000 million in 2000 (Bolling and Somwaru, 2001) b. Introduction of foreign capital and competition has also boosted investments in marketing and advertising, which has proved effective for generation of sales of highly processed foods in nations of middle and low incomes (Hawkes, 2006)
o Trade liberalisation has enabled greater availability of highly processed, calorie-rich, nutrient-poor food in developing countries, but further research needs to be done to better understand the relation between trade policy and diets
a. We have some information about the growth of processed food sales; we note 29% annual growth in developing countries versus 7% in nations with high incomes (Hawkes, 2005) b. We also have seen a doubling in food import bills as a share of GDP in the 30 years up to 2004, mostly made up of processed foods (FAO, 2004) c. However, evidence for consumption patterns of processed foods and its determinants in developing countries are still very much needed
CONCLUSIONS: Blouin et al., 2009 (‘Trade and social determinants of health’)
In many political systems, health authorities are not in a position to influence directly trade policy decisions at the national level
o Nevertheless, their existing knowledge on the determinants of population health and their jurisdiction over social and health policies place policymakers in a privileged position to ensure that, in a increasingly global economic environment, domestic policies and regulations are designed to enhance social protection and to harness economic benefits of trade through redistributive policies
o In the context of open economies, in which vulnerability to sudden change and increased economic insecurity is greater than in protected national markets, systems of social protection become more important than ever to reduce health risks related to psychosocial stress and material conditions
a. Social protection should stabilise incomes, distribute gains of globalisation to groups that would otherwise be excluded, and support development of new capabilities (ILO, 2004)
b. These programmes should be designed in a flexible manner, allowing them to be easily scaled-up in response to large economy-wide shocks
c. Important initiatives should be identified a priori, with commitments for their protection from budget cuts during a crisis
d. The list of safeguarded programmes should be guided by an overall strategy to stop human development reversal, with a focus on prevention of long-term health effects of economic insecurity (Labonté et al., 2007)
e. In low-income countries, where very limited financial resources are available to fund social protection, initiatives should focus on interventions that contribute to long-term poverty reduction and that have multiplier effects, such as health insurance schemes that protect against unexpected medical expenses (Van Ginneken, 2003)
o To ensure that trade liberalisation in the agriculture and food sectors does not translate into unhealthy diets and rises in diet-related chronic diseases in developing countries, several policy options can be considered. One idea is intervention to control the price of healthy and unhealthy foods
a. Countries such as Japan, Norway, and South Korea have provided major support for local agriculture and maintained high import tariffs, and they have relatively low levels of obesity compared with more liberal countries such as the USA and Australia
b. However, evidence is scarce of a causal relation between price controls and obesity (Schmidhuber, 2004)
o Information asymmetries between food companies and consumers is another potential area for intervention
a. Greater regulation of marketing and advertising of food, especially to children, is receiving much more attention (Nestle, 2006)
b. Beyond nutrition education to help individuals make better food choices, collective responses—such as regulations about the formulation and nutritional labelling of processed food—also need to be examined closely (Chopra et al., 2002)
Will gender discrimination legislation—making it illegal to discriminate against certain women—improve the health of women?
De jure vs. de facto discrimination
o De jure = laws technically in place
o De facto = laws as they exist in practice; lived experiences, prevailing norms/values
Emerging debate around the ability of institutional/formal/de jure mechanisms to effectively legislate against de facto discrimination/inequality
What is the difference between absolute and relative poverty and how might they affect health differently?
‘Health and longevity are intimately related to [relative] position in the social hierarchy’ (Marmot, 2004)
o Relative position in the social hierarchy, rather than absolute wealth, is what matters in determining health inequalities
How would a universal basic income affect health inequalities? Who, if anyone, would stand to benefit most from this policy?
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Describe one policy you would implement to reduce health inequalities. Explain why it would achieve its goal.
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Argentina recently agreed a lending arrangement with the IMF. How might this affect the health of their population?
Initiated as a response to low- and middle-income countries (LMICs) defaulting on their loans from international financial institutions en masse, structural adjustment programs involve the imposition of policies falling within four general realms: (1) liberalization of trade, (2) deregulation of industry, (3) privatization of resources and sectors, and (4) stabilization of fiscal and monetary policy (Woods, 2009)
Typical stabilisation policies include (Lensink, 1996; White, 1996):
o balance of payments deficits reduction through currency devaluation
o budget deficit reduction through higher taxes and lower government spending, also known as austerity
o restructuring foreign debts
o monetary policy to finance government deficits (usually in the form of loans from central banks)
o eliminating food subsidies
o raising the price of public services
o cutting wages
o decrementing domestic credit.
Long-term adjustment policies usually include (Lensink, 1996; White, 1996):
o liberalization of markets to guarantee a price mechanism
o privatization, or divestiture, of all or part of state-owned enterprises
o creating new financial institutions
o improving governance and fighting corruption (from the perspective of a neoliberal formulation of ‘governance’ and ‘corruption’)
o enhancing the rights of foreign investors vis-à-vis national laws
o focusing economic output on direct export and resource extraction
o increasing the stability of investment (by supplementing foreign direct investment with the opening of domestic stock markets)
These conditions have also been sometimes labeled as the “Washington Consensus”
The relevant literature suggests that, assuming the former does indeed have a causal bearing on the latter, the path from structural adjustment programs to adverse health outcomes operates via the following causal mechanisms: through policies which carry a direct impact on the health systems of a country; through policies which result in indirect health consequences; and/or through policies which negatively alter the social determinants of health (Kentikelenis, 2017)
‘Direct effects’ pathway
o Most typically, the ‘direct effects’ pathway from structural adjustment programs to health outcomes is thought to be actualized via austerity-compelled reductions in government expenditures, often resulting in cuts to funds earmarked for public health services, which in turn manifests as a paring down of staff, treatment, and/or services
o There exists further concern that any public sector hiring or wage freezes—expected by-products of austerity and other classic stabilization measures—will prove sufficient incentive for doctors to abandon lower-income countries for medical regimes likely to prove more financially lucrative
‘Indirect effects’ pathway
o The ‘indirect effects’ of structural adjustment on health systems can be conceived of as mediated by macroeconomic and institutional reforms, with international financial institutions frequently encouraging currency devaluation as one piece of their broader stabilization policies, increasing import prices, and therefore limiting the accessibility of medicines and equipment entering a country (Breman and Shelton, 2006)
o If tariffs and customs are removed as part of a trade liberalization strategy, then trade tax revenues will, at least temporarily, reduce accordingly, further jeopardizing the money available to fund healthcare expenditures (Baunsgaard and Keen, 2010)
Social determinants of health
o The economic reform programs instituted by the IMF and World Bank are argued to yield detrimental health effects by altering macro-level factors known as ‘social determinants of health’ (Wilkinson and Marmot, 2003)
o Deregulation of industry—a component of structural adjustment programs meant to increase the extent to which countries are ‘friendly’ to business—can induce negative environmental externalities, which carry plausible implications for the health of a population, especially insofar as one considers issues such as water cleanliness and general sanitation (Shandra et al., 2008, 2011)
Critics have condemned the privatization requirements frequently attached to IMF loans, arguing that when resources are transferred to foreign corporations and/or national elites, the goal of public prosperity is replaced with the goal of private accumulation
Rick Rowden, 2009: “The Deadly Ideas of Neoliberalism: How the IMF has Undermined Public Health and the Fight Against AIDS”
o Claims that the IMF’s monetarist approach towards prioritizing price stability (i.e., low inflation) and fiscal restraint (low budget deficits) was unnecessarily restrictive and has prevented developing countries from being able to scale up long-term public investment as a percentage of GDP in the underlying public health infrastructure.
o Cites consequences such as chronically underfunded public health systems, leading to dilapidated health infrastructure, inadequate numbers of health personnel, and demoralizing working conditions that have fueled the “push factors” driving the brain drain of nurses migrating from poor countries to rich ones, all of which has undermined public health systems and the fight against HIV/AIDS in developing countries
o COUNTERARGUMENT: it does not necessarily hold that reducing funding to a program automatically reduces its quality—there may be factors within these sectors that are susceptible to corruption or over-staffing that causes the initial investment to not be used as efficiently as possible
Studies have shown strong correlations between structural adjustment programs (SAPs) and tuberculosis rates in developing nations (Stuckler et al., 2008)
The fundamental problem of causal inference
o Defenders of the legacy of structural adjustment programs maintain that, because the LMICs subjected to externally-imposed regulations were already in the grip of economic crises, the policies enacted served to prevent the realization of a worse reality; i.e., yielded negative consequences less severe than those which would have materialized in the absence of these programs
o Paul Holland addresses the issue of the counterfactual in what he terms the Fundamental Problem of Causal Inference, which states that “[i]t is impossible to observe the value of Yt(u) [treatment] and Yc(u) [control] on the same unit and, therefore, it is impossible to observe the effect of t on u” (Holland, 1986)
As it relates to countries on the receiving end of IMF lending arrangements, Holland’s Fundamental Problem of Causal Inference tells us we cannot observe the health outcomes that would have occurred in the absence of an IMF loan, since these countries were in fact ‘exposed’ to the ‘treatment’ in question (i.e., did receive a loan from the IMF)
o HOWEVER, this is not to suggest that claims of causal inference are necessarily meaningless—only that they require critical scrutinization of any assumptions implicitly made, particularly insofar as assumptions of homogeneity or invariance are concerned
o What is the most plausible alternative to the lending arrangement in place, and how are population health outcomes likely to be affected by this hypothetical reality?
o Is it probable that some degree of austerity would be required even in the absence of an IMF loan, and/or would institutional capacity be weakened to the point of further exacerbating existing inefficiencies in the healthcare system?
