Wealth and health: How people are escaping inequality

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Economic Observer Many/Articles The original name of "Escape from Inequality" is "The Great Escape", which means "The Great Escape". Angus Deaton said, "The greatest escape in human history is the escape from poverty and death." Inequality is actually a by-product of the process of mankind's great escape.

The word "inequality" is more a description of reality than a guideline for value judgments. In fact, inequality is not always a bad thing. Countries around the world are at different stages of development, and there is a gap between rich and poor countries. However, early-developing countries may experience twists and turns and go astray in the development process, while late-developing countries have the opportunity to learn from experience and overtake others around the corner. For citizens of various countries, some people will get rich first, and they can "get rich first and then get richer later", allowing everyone to enjoy a higher standard of living.

Of course, the side effects of inequality are obvious to all. U.S. Justice Louis Brandeis made a famous assertion that the United States is either a democracy or wealth is concentrated in the hands of a few people. He cannot have both. Looking back at history, the process of human beings escaping from poverty has been difficult and tortuous. Inequalities in health, wealth and other aspects have arisen between countries that have escaped poverty and those that are still struggling. Human beings may have to continue to escape from inequality.

About health inequalities

According to Deaton, health is the starting point for discussing issues of well-being (welfare). People must survive before they can pursue a happy life. A classic saying is that health is the "1" in the front, and everything else, including wealth, is the "0" in the back. Without the "1" of health, the whole life will be "0".

For those who study health and hygiene, individual health is determined by various factors, but group health (especially life expectancy) is closely related to income level. Demographer Samuel Preston proposed the "Preston Curve" in 1975. Redrawing the curve using 2010 data shows that in countries with per capita income below $10,000, income growth is highly correlated with increases in life expectancy; for countries with per capita income above $10,000, this correlation weakens. , but still exists. Roughly around the time when per capita income is US$10,000, countries gradually undergo an epidemiological transition: as each country progresses, the age of death of its citizens is delayed, and the age of death of the population is shifting from childhood to old age. At the same time, the cause of death has also shifted from infectious diseases to chronic diseases.

In particular, in countries with per capita income below US$10,000, infectious diseases are generally the leading cause of death; in countries with per capita income above US$10,000, chronic non-communicable diseases are more likely to cause death. In 2017, China's per capita GDP was close to US$9,000, and malignant tumors and cardiovascular and cerebrovascular diseases have become the main causes of death among urban residents. We are on the threshold of an epidemiological transition.

Although income is related to health, it is not the only determinant of health. Deaton compared the Preston curve in different years and found that it moved upward as a whole; even if income did not increase, average life expectancy was also increasing over time. This may be attributed to advances in scientific and medical knowledge, which, at least in Deaton's view, is more critical than income growth. Because scientific and medical knowledge can spread rapidly across borders, mortality rates have been declining and life expectancy has increased in countries around the world in recent years, and low-income countries are narrowing the life expectancy gap with high-income countries.

This narrowing of the gap does not mean that health disparities are shrinking. Economists who study health often use mortality and life expectancy as the gold standard, but the comparability of these standards is controversial. Life expectancy can be converted into mortality rates at various ages and used as the indicator of greatest concern, perhaps assuming that life is meaningful and that the longer people live, the better.

As far as the entire country is concerned, we generally believe that groups that live longer are healthier: In an era when life expectancy is less than 40 years old, there is a reason why Chinese people are called the "sick men of East Asia." It should be pointed out that the calculation formula of life expectancy determines that it is biased towards improving the health of young people. If the mortality rate of newborns and the mortality rate of the elderly decrease to the same extent, the former can increase life expectancy more.

A particularly classic example is China since 1949. In the first thirty years of New China, China carried out various "patriotic health campaigns" and established a three-level health network in counties and villages, allowing barefoot doctors to provide farmers with the most basic medical services through rural cooperative medical care. China's neonatal mortality rate It dropped from 8.08% in 1957 to 4.81% in 1977, rapidly pushing up life expectancy. Nowadays, many low-income countries achieve reductions in mortality by reducing child mortality; high-income countries achieve this by extending the life span of the elderly.

If the gap in life expectancy between countries in the world is narrowed, it can be directly regarded as the world becoming more equal; then it is actually assumed that the death of young people deserves more attention than the death of old people. When looking at overall population mortality rates, the claim that the gap has narrowed is not valid and international health inequalities continue. While child and adult mortality rates are declining globally and some countries have escaped poverty and disease, one billion people still suffer from material and educational deprivation and do not live any longer than their ancestors. The world created by Battle Escape is not that rosy. Compared to 300 years ago, there is even greater inequality for those who are still left behind.

History of improving health

Improvements in health do not come in a steady stream. Although health levels in various countries have gradually improved over the past few decades, humanity's so-called great escape may be temporary.

Historically, the life expectancy of Americans was 47.3 years in 1900 and reached 77.9 years in 2006. The overall health status is getting better and better. However, the sudden influenza pandemic in 1918 caused a sharp decline in American life expectancy. Although this decline rebounded quickly after the influenza subsided, the improvement of health levels is not one-way, and a public health crisis may reverse decades of efforts. The Chinese people who experienced the SARS incident in 2003 should understand this truth.

In Africa, epidemics of infectious diseases continue to reoccur, and the AIDS epidemic has caused a sharp decline in life expectancy in countries such as South Africa. From the end of the 20th century to the beginning of the 21st century, life expectancy in the African country Botswana dropped from 64 years to 49 years; and it was even worse in Zimbabwe, where the average life expectancy in 2005 was lower than in the 1950s.

In the same way, the comfort level of human life does not advance steadily over time. Improvements in health are relatively recent. There appears to have been no steady increase in life expectancy during the thousands of years of the agricultural era, and income per capita and life expectancy showed no correlation during this period. This phenomenon continued into the Age of Enlightenment.

In the 300 years since the Age of Enlightenment, the changes in life expectancy in European countries were still irregular. However, the British aristocracy has experienced a steady increase in life expectancy. Starting in 1775, the life expectancy gap between the British ducal family and the general public gradually widened; by 1850, the gap between the two was close to 20 years. Deaton speculates that this was the earliest stage of globalization, when most inventions (especially treatments) were expensive and unstable, and only wealthy and courageous aristocrats dared to try them. Take smallpox as an example. People have long discovered that vaccination with cowpox can prevent smallpox. However, if the vaccination fails, you may get smallpox instead, so people are unwilling to vaccinate. The British Duke family was the first to try and successfully reduced the deaths caused by smallpox. The general population widens the gap in life expectancy.

Beginning in 1800, nutrition and public health began to be linked to increases in life expectancy, and it was from this time on that the gap in life expectancy between countries around the world gradually widened. During this period, Western countries achieved life expectancy mainly by reducing infant mortality, and it was discovered that the decline in infant mortality was not related to the emergence of new drugs. Thomas McKeown, the famous founder of social medicine, used a series of charts to prove that mortality rates from many diseases were already declining before effective treatments were available. The root cause of people's health improvement may lie in economic and social progress, especially the improvement of nutritional levels and the optimization of sanitary conditions. The progress mentioned here does not mean economic growth. In fact, the timing of the onset of economic growth in Western European countries is inconsistent, but the timing of the decline in child mortality is surprisingly consistent. Perhaps it is more accurately called an improvement in public health measures.

In Europe in the 19th century, "urban" sanitary conditions were poor, the population was densely populated, and infectious diseases were very serious. Therefore, the life expectancy of the urban population was lower than that of the rural population. At this time, people had not yet grasped the theory of bacterial disease. London's two waterworks took water from downstream of the sewage outlet for citizens to drink, which promoted the spread of cholera. Later, a water plant moved its water intake upstream where the water quality was purer, and the incidence and deaths of cholera among the residents served by the water plant decreased. A physician named John Snow discovered the route of cholera transmission from changes in its incidence, and this study became the earliest "natural experiment" in the history of public health.

After people acquired health knowledge, it failed to be quickly translated into public policies. For example, establishing a safe drinking water supply system can certainly help reduce the spread of disease and improve health, but this system requires a lot of manpower, material and financial resources, and requires a capable government to organize and build it. In European countries, citizens of various countries have adopted various political struggles to finally advance the development of public health.

Medical Development and Economic Burden

Since the 1930s, new lifestyles, the application of drugs, and the promotion of vaccination and vector control have continued to promote the growth of life expectancy in various countries, and the role of medical care has become more prominent. As mentioned earlier, the emphasis on basic medical services in the first thirty years since the founding of the People's Republic of China has led to a rapid decline in China's infant mortality rate; in fact, this story is not over. After the reform and opening up, the rural collective economy gradually disintegrated, the grassroots medical system continued to weaken, and the economy grew rapidly. The infant mortality rate continued to decline until the late 1990s. After 2003, the Chinese government invested a lot of money to promote full coverage of medical insurance. Although the medical system is still far from perfect, the health level of the people has begun to steadily improve again.

Being born in a low-income country is not good luck. There are still a large number of people in the world who do not realize that medical insurance can help them protect themselves from illness and premature death. Even if their countries' health investment is very low, they are still very satisfied with the health care system.

For countries that attach great importance to medical security, financial burden has become a new problem. Seeking medical advice costs money. The United States spends 18% of its national income on medical care. With such a high cost, it is necessary to consider whether it is worth it. The "Dartmouth Health Map" records the health insurance expenditures of the elderly in the United States: There are huge differences in health insurance expenditures between different regions in the United States, but this difference has no obvious correlation with medical needs and medical effects. Such high medical expenses will directly crowd out other living expenses. Not only that, medical expenses are often not actively chosen by patients. Even with insurance, the rapidly rising insurance costs put every resident under pressure. How to make the medical system cheap and efficient has become a difficult problem facing the government.

In addition to medical security, promoting healthy lifestyles has become an important entry point for countries to improve national health. Take smoking as an example. In the first half of the 20th century, the smoking population expanded globally. The U.S. Department of Health released the "Report on the Impact of Smoking and Health" in 1964, prompting many U.S. citizens to quit smoking. The then U.S. Surgeon General, Dr. Luther Terry, was a smoker himself and smoked in his car before the report was released. Aides reminded him that at the press conference the public might care about whether he smoked, but he dismissed it. When we arrived at the scene, the first question we asked was whether the minister himself smoked. After some hesitation, Terry announced that he would quit smoking, and the American people followed suit. After that, U.S. tobacco sales began to fall back.

However, people's lifestyles are connected to commercial interests, and commercial interests will in turn affect people's lives. In the United States, tobacco manufacturers have successfully tied smoking as a "right" to women's movement for equal rights, at the expense of American women's health. From a global perspective, high-income countries are gradually regulating and taxing tobacco, while low-income countries are either unable to regulate or unwilling to do so, and have become a sales paradise for multinational tobacco companies. The difference in national governance capabilities has undoubtedly strengthened the health insecurity. equality.

The gradual increase in life expectancy cannot fully reflect the new problems faced by countries around the world in the process of improving health. After the 1970s, the United States and other countries mastered new treatment technologies for cardiovascular diseases, and cardiovascular mortality began to decline. But cancer, which ranks second to cardiovascular disease, is difficult to treat: many new treatments for cardiovascular disease are cheap and efficient, but new treatments for cancer are very expensive.

In addition, in addition to the length of life, people have also begun to care about the quality of life. Although the decline in mortality is worthy of joy, the morbidity rate has not improved at all. For low-income countries, medical technology spreads rapidly in the context of globalization, and prevention and control methods for cardiovascular diseases and cancer are also rapidly spread to these countries; however, the patent system of medicines makes medicines expensive, and a small number of rich people can take the lead in using expensive medicines. imported drugs, most poor people continue to lack medical care, and first-world medical advances have exacerbated health inequalities within these countries.

Income equality in the era of great differentiation

What economist Lant Pritchett calls the "era of great differentiation" has arrived. From 1820 to 1992, the world's average per capita income increased 7 to 8 times, and the proportion of poor people in the world's population dropped from 84% to 24%. However, the gap between rich and poor countries shows no sign of narrowing. Although low-income countries have a "latecomer advantage" in theory, judging from the reality of income growth in various countries, the income levels of rich and poor countries have not shrunk significantly, and the inequality between countries has not changed much. In fact, if China is excluded, the absolute number of poor people in the world is increasing; the decline in the proportion of the world's poor population is largely due to the rapid development of China's economy.

Within high-income countries, income inequality has also become a serious challenge. Economists always like to say the "Pareto Principle". As long as the income growth of high-income people does not harm the interests of low-income people, everyone is happy. However, in reality, we always find that the rapid income growth of high-income earners may cause damage to the welfare of other people. In some backward countries in Africa, the high-income groups in power have stronger predatory capabilities. They can take the nascent economy of the region as their own, and they can also extinguish the fire of innovation and innovation in order to ensure their dominance. In this way, even if a country has short-term economic prosperity, it cannot ensure long-term economic growth.

Sometimes, the government needs to choose between national economic growth and people's income growth. Take the difference between France and the United States as an example. Although France's growth is not as rapid as that of the United States, if you compare the average income of 99% of the people in the two countries, you will find that France's growth rate is much faster than that of the United States. In other words, excluding the top 1% of income earners, the French are better off than the average American. Sacrificing some economic growth rate and improving the welfare level of the vast majority of people may be an acceptable choice.

In order to narrow the gap between rich and poor countries, high-income countries have provided a lot of help to low-income countries, but the effects of these help and aid are not satisfactory. Deaton directly calls the aid behavior and expectations of high-income countries the "aid illusion."

Aid to low-income countries faces a paradox: when the recipient country has the internal conditions for economic development, aid is not necessary; but when the internal conditions are not enough to support economic development, aid will not play a good role, or even It may solidify its unfavorable conditions and play a detrimental role. Considering that most aid is carried out between governments, the goal of many aids is not to completely lift people out of poverty, and aid agencies do not conduct careful assessments. Such aid often does not bring about an improvement in income. Some projects have attempted pilots and evaluations, but when the projects were rolled out on a large scale, the actual results were completely different from the pilot results.

Not only that, large amounts of external aid have changed the government's revenue structure. The government no longer needs to obtain fiscal revenue from the country's economic growth, and has no incentive to promote economic growth. What's more, the governments of recipient countries use their poor people as hostages to extract money from the aiding countries. The more serious the poverty, the more aid they receive. Deaton also criticized the idea of ​​"population control" that Western countries instill in low-income countries. In the view of some economists and politicians, the total amount of various resources in the world is fixed, and an increase in population will reduce per capita resources; but from real experience, in the past few decades, global mortality has declined and population has grown rapidly. People's living standards are improving. It can be seen that whether population increase will cause poverty depends on the costs of population growth and the benefits brought by population size.

Of course, we have to admit that real money aid has played some "relief" role. International aid can help low-income countries improve sanitation, thereby saving lives. The 1978 Declaration of Alma-Ata emphasized the importance of "health for all" and also emphasized that basic medical security is a means to achieve this goal. With the support of international aid, low-income countries can also provide some traditional public goods (safe water, basic sanitation, pest control, etc.). This type of health-promoting, life-saving assistance is meaningful and necessary. If high-income countries sincerely want to assist low-income countries, they can provide experience and lessons to late-developing countries, so that they can avoid detours and develop rapidly. Developed countries that are truly responsible should relax trade restrictions and immigration restrictions, allowing backward countries to export goods and services to developed countries and realize global wealth flow.

People always stand at one end of history, looking back at the past and feeling that they have made unprecedented progress. Those civilizations that existed for a long time and then collapsed all thought that they would last forever. The achievements that mankind has made in the past and the unequal dilemma it faces now may be an episode in history. The exodus continues, and the escape from inequality has only just begun. What attitude should we have towards the future of humanity? Maybe it’s cautious optimism.