Health and Development
March 28, 2011
Akanksha Bajaj, Aaron Lewis, Mattie Wheeler
Image Source: WHO Fact Sheets
Key Facts
• Nearly 9 million children under the age of 5
die every year
– Around 70% of these early child deaths are due to
conditions that could be prevented or treated with
access to simple, affordable interventions
– Over one third of all child deaths are linked to
malnutrition
• In low-income countries less than a quarter of
all people reach age of 70, and people die
predominantly of infectious diseases
The enjoyment of the highest attainable standard of health is one of the fundamental rights
of every human being without the distinction of race, religion, political belief, economic or
social condition.
-WHO Constitution
UN Millennium Development Goals
Death Distribution & Child Mortality
Image Source: WHO Fact Sheets
Why Study Health and
Development?
• Preston curve: strong correlation between per capita income and life
expectancy, but is there a causal relationship between poor health and low
GDP per capita?
• Poverty trap? Income is a function of health, but health is also a function of
income
• Wealthier is Healthier (Pritchett & Summers, 1996): Higher income leads
to good and services that promote health, such as better housing, better
nutrition, more education, as well as public health projects
• Better health allows adults to earn more income and children to perform
better on tests
• Health is also correlated with income within countries – these are called
“health inequalities”
• Researchers need to understand the relationship between health and
development in order to determine the most effective policy intervention.
– Is it more effective to focus on programs that raise GDP without specifically
focusing on health care?
– Or should we target health through large public health initiatives like
vaccination campaigns or large-scale sanitation projects?
Key Questions about Health and
Development
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Are health improvements an instrument for achieving economic growth? That is,
does better health cause an increase in GDP per capita or just an increase in “overall
welfare”?
Does increasing GDP per capita cause better health (i.e. increased life expectancy)
or are separate measures necessary?
What are the barriers to better health in poor countries and how much of a role do
they each play?
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Lack of infrastructure
Lack of funding
Lack of political will
Lack of education
What are the most effective ways to improve health in developing countries?
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Vaccination
Medicine distribution (i.e. antibiotics)
Public health projects like waste removal or water sanitation
Construction of medical clinics
Education (particularly of women)
The Determinants of Mortality
Cutler, David, Angus Deaton and
Adriana Lleras-Muney
Proponent Section
The Preston Curve: Life Expectancy
versus GDP Per Capita
Historical Decline in Morality:
Introduction
• Little increase in life expectancy from huntergatherers to 1700
• Significant mortality decline begin in 18th century
• Most of historical reduction in mortality occurred
at younger ages
• Pattern explained by decline in infectious diseases
– Between 1848 and 1971, 95% reduction in infectious
disease mortality
– Infants and children are most vulnerable to infections
• What are the relevant factors in reduction of
infectious diseases?
Expected Age at Death,
England and Wales
Historical Decline in Mortality:
Possible Causes
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Improved Nutrition
Public Health
Urbanization
Vaccination
Medical Treatments
Long-Term Reach of Early-Life Factors (also
known as the “womb with a view” hypothesis)
Historical Decline in Mortality:
Improved Nutrition
• McKeown 1976: residual analysis showing nutrition as
crucial factor; however, unconvincing.
• Fogel 1997: used increase in caloric intake (measured in
agricultural output and changes in adult height) to show that
nearly all reduction in mortality attributed to improved
nutrition
• Arguments against Fogel:
– Life expectancy was the same in 1600 and 1820
– Skeletal remains show people were taller during the early
medieval times
– English aristocrats had no higher life expectancy than rest of
population, despite better nutrition
– Two way interaction between disease and nutrition—so some of
the exogenous influence was disease, not just nutrition, and
therefore interventions that targeted disease (such as public
health) were more significant
Historical Decline in Mortality:
Public Health
• Preston estimates: only 15% of increase in life
expectancy between 1930s and 1960s in result of
increases in only income
– Even at a given income, people live significantly
longer today than in the past
• Public health offers an explanation for this
• Macro public health: big public works projects
• Micro public health: change encouraged by public
sector but carried out by individuals
• Acceptance of germ theory of disease in 1880s
led to new public health initiatives
Historical Decline in Mortality:
Urbanization
• Most evidence shows urbanization caused lack
of improvement in mortality in mid-19th
century
• Greater spread of disease in large cities
• Effect of unsanitary conditions > nutrition
effect
Historical Decline in Mortality:
Vaccination
• First important medical intervention began early 20th
century
• Important vaccines:
– Rabies, plague, diphtheria, pertussis, tuberculosis, tetanus,
yellow fever, polio, measles, mumps, rubella, hepatitis B
• However, direct mortality from these diseases was
somewhat rare prior to introduction of vaccines
• Reduction in these diseases as causes of death represent
only 3% of total mortality reduction (excluding
tuberculosis)
• Indirect consequences of eliminating infectious
diseases
Historical Decline in Mortality:
Medical Treatments
• Development of new treatments for people with diseases
– Antibiotics, developed 1930s-1940s caused
– Other intensive medical medical interventions targeting
cardiovascular disease
• Infectious disease mortality declined to current level by
1960
• Cardiovascular disease mortality has declined by over 50%
since 1960
• Reduced infant mortality due to neonatal care
• Concurrent decline and convergence of mortality rate in
developed countries shows importance of medical
technology and smoking behavior
• Today, according to Fogel, health care system is important
for reducing morbidity but not mortality
Historical Decline in Mortality:
Fetal Origins
• Better nutrition from decades ago is having its effect today
• Correlation between health in adulthood and birth weight,
even when controlling for socioeconomic status
– What other approach could researchers take to test the fetal
origins theory?
• Examine late-life health of children who were in utero
during famines
• Seasonality of life expectancy
• Environment during childhood predicts onset of disease in
adulthood
• Some of decline at end of 20th century can be attributed to
improved diet and public health during childhood
Historical Decline in Mortality:
Conclusions
• Three phases in mortality reduction:
1. Mid-18th to mid-19th c.: improved nutrition and
economic growth played large role
2. End of 19th-20th c.: public health mattered more
1. Negative effect of urbanization
2. Positive effect of clean water, waste removal, personal
health advice
3. 1930s-present: medicine, including vaccinations,
antibiotics, personal interventions
Determinants of Mortality in Poor Countries
Determinants of Mortality in
Poor Countries
• 30% of deaths in poor countries are children, compared
to <1% in rich countries
• Most deaths in poor countries are from infectious
disease, instead of cancer and cardiovascular disease
• Improvement in life expectancy since WWII:
– India and China rose by 30 yrs
– Life expectancy in Africa rose 13 years until 1980s
• How to account for this improvement?
• Still, great inequality between health in poor and rich
countries
– Not primarily due to lack of treatment
Determinants of Mortality in Poor
Countries: Risk Factors
• Risk factors for mortality in poor countries (according to WHO 2003)
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Unsafe sex
Unsafe drinking water
Malnutrition
Indoor smoke
What affects these risk factors?
Low quality and inadequate funding of health delivery
Lack of political demand for improvement in health provision
Successful interventions have mostly been “vertical” campaigns
– These do not improve domestic health care systems
– Current lack of support for international immunization campaigns 
slowdown in rate of reduction of infant mortality in 1990s
• Importance of social factors
– Changes in income and literacy
Determinants of Mortality in Poor
Countries: Economic Growth (1/2)
• Assuming Preston curve is causal relationship, effects of income on
health are strong at low levels of income
– Emphasis on nutritional factors as well as infrastructure of public
health
• Pritchett and Summers (1996): used cross-country regressions to
show income is most important factor
• This explanation favors policy that downplay role of deliberate
health intervention, such as economic liberalization
• However, cross-country data shows no relationship between changes
in life expectancy and economic growth between 1960 and 2000
– India and China actually show negative correlation between economic
growth and reducing infant and child mortality
Determinants of Mortality in Poor
Countries: Economic Growth (2/2)
• Why doesn’t economic growth improve health without
deliberate public action?
• Paradoxical because income can bring better nutrition,
better housing, ability to pay for public health projects
• Possible explanations?
• Acemoglu and Johnson (2005): improvements in health
technology actually reduce GDP per capita if they lead
to large increases in population
– Effect of economic growth on health has been hidden by
negative effects of population growth in WWII period
Determinants of Mortality within
Countries: Introduction
• Evidence from different time periods and counties all
show higher mortality rate for individuals with low
income, low education, low social status
• In United States, inverse correlations between
education, income, and mortality
• Similar gradients in developed countries
• World Bank study shows negative link between infant
mortality and index of living standards (lack of data on
adult mortality in poor countries)
• Why do these inequalities exist? Are they consistent
with accounts of mortality decline and differences in
mortality between rich and poor countries?
Determinants of Mortality within
Countries: Medical Care & Resources
• People with high income receive more health care
• However, studies show that incidence of health
conditions is higher among lower social classes
(before health care system is even a factor)
• EX: Britain’s class-based differences in health
were not affected by National Health Service
• No evidence rising living standards change the
health gradient
Determinants of Mortality within
Countries: Health-Related
Behaviors
• Smoking, drinking, exercise, eating habits, use of
preventative care all correlated with measures of
socioeconomic status
• However, even when these differences are
controlled for, health gradients by status persist
• Also does not explain why people from different
socioeconomic classes behave differently
– EX: due to widespread campaign, knowledge of
detrimental effects of smoking in the U.S. is nearly
universal
Determinants of Mortality within Countries:
Social Structures, Stress and Health
• Poor health of low status people is due to “psychosocial stress”
• Supported by biological evidence
– Cumulative stress leads to increased probability of disease
• Concerns with this theory:
– Socioeconomic status encompasses a range of variables like income,
education, race, and this explanation does not differentiate between
them
– Reverse causality  poor health leads to low income
• Poor health is leading cause of retirement or dropping out of the labor force
• Effects of education more consistent than effects of income with
regard to socioeconomic status
– Numerous studies show correlation between maternal education and
reduction in infant and child mortality in developing countries
– However, also possibility of reverse relationship because children who
have poor health enter adulthood with lower educational achievement
Determinants of Mortality within
Countries: Conclusions
• In many cases, poor health causes low income,
rather than the reverse
• Direct positive effect of education on health
– This also means that some of post-1970 decline in
mortality in U.S. can be attributed to education,
meaning less attributed to medical care
The Determinants of Mortality:
Final Conclusions
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Acknowledgement that evidence is weak for many links in argument
Explanation for decline in mortality: knowledge, science, technology
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Critical role of germ theory of disease in changing public health and personal behavior
Increased productivity allowed better nutrition, better housing, better sanitation
Knowledge of effects of smoking
Scientific innovations in medical procedures, drugs
Health innovations for poor countries: oral rehydration salts, freeze-dried serums
Role of income less important
– Improvements in income and health come from new ideas and new technology
– Public health initiatives require institutional capacity and political willingness to implement
new technology, not just income
– Lower income explains much of correlation between income and health
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Great incentives for discovery of health-enhancing knowledge and technology
– But, these will increase gradient
– Greater speed of introduction of knowledge and technology will raise health gradient
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Gaps between countries may also widen, since there is less incentive for research
and discovery of diseases that affect the poor (such as malaria and tuberculosis)
The existence of treatment does not mean that it will be made available in poor
countries
Goal of public policy should be to improve equality of access to such technologies