Let me start with saying how happy I am to be living in a new democracy. Today is election day in South Africa, as voters go to the polls for the fourth municipal elections in the history of the Republic of South Africa. Although I’m an observer in this democratic process, the ability to witness (relatively) peaceful and procedural elections in a country where a majority of people were disenfranchised until just 17 years ago is a privilege.
But what does democracy have to do with health? I’m in the middle of Amartya Sen’s classic piece on development “Development as Freedom”, in which Sen makes his compelling argument that the entire framework of development should focus on individual freedoms. In this context, democracy has pretty much everything to do with our health and wellbeing.
Theory and logic seem to be aligned. Democratically elected politicians have the correct incentives to develop and implement policy that improve public health, considering that healthy voters will likely be more supportive in elections than unhealthy ones. Conversely, despots and entrenched political elites have less incentive to support public health as healthier populations have greater strength and therefore greater capacity to revolt.
Is there proof that democracy and health are linked? Yes indeed. Most famously, Sen cites repeatedly the fact that no major famine has occurred in a functioning democracy. To take this a step further, Jennifer Ruger provides an interesting analysis of three separate health crises in China, including the famine in the late 1950’s and the more recent SARS outbreak. Based on the political reaction and outcomes of these crises, Ruger concludes that “the absence of democracy…can have deleterious effects on health.”
But wait. There are also some striking examples to the contrary. Pre-reform China had one of the world’s most innovative and far-reaching public health systems, including the cadre of barefoot doctors who preceded today’s community health workers. Economic reform has dismantled much of the public health system, leading to the decline that is witnessed in parts of China today. India, on the other hand, has a thriving democracy and yet exhibits some of the most striking public health challenges in the world today.
In a New York Times book review, Michael Massing posed the question back to Sen, who commented “it would be a misapprehension to believe that democracy solves the problem of hunger.” In other words, the relationship between democracy and health is not a linear, cause and effect type. The issue is substantially more complex.
I would venture that South Africans agree that democracy alone is not an answer to society’s ills, nor the health of the public. Today, as South Africans head to the polls, activists and protestors are standing amongst them, angry at the slow pace of delivery which has followed the post-apartheid promises. Since 1984, HIV/AIDS has ravaged the nation and skills shortages have wreaked havoc on an overburdened public health system.
If democracy is not the solution, it is at least the channel through which the people’s voices can be heard.