Are we really feeling healthier or just dying less?
Questions for José Tapia
For years now, I have been traveling back and forth between Paris and southern Europe, more specifically Portugal. Since the imposition of austerity policies on Portuguese society, I face a worse social situation in this small country, probably the poorest in Europe, every time I go back there. While the social consequences of austerity and the destruction of public services are probably less dramatic there than in Greece, they are nonetheless terrible. This is to introduce the few comments that follow on the recent interview of José Tapia (JT), “Health and Economic Crises” published in the Brooklyn Rail in October, 2014.
I found the ideas expressed by JT very interesting and thought provoking, in the light of what I note empirically when I am in Portugal with my friends. The trouble is that these ideas don’t fit with what I know and observe, with the life and health problems I experience. In his interview, JT says, “When facts do not fit with general views about society, someone will soon appear to ‘demonstrate’ that they do not exist.” That’s exactly the feeling I had reading some parts of the arguments and analysis in the interview. Where does all the new misery, human suffering, and destruction I encounter fit in with the idea that recession does not bring about poorer health? Should I decide that what I know and what I see does not exist?
I am not a specialist on health or economics. Nor am I very fond of statistics, figures, and graphs, although I admit they can often help us understand issues. I respect the work JT and others have been doing on this subject, and it may well be that my comments and thoughts are not on the same level as their approach—that I am on the wrong track. Still, if theoretical thought, analysis, and abstraction have meaning for me, it is because they enable us to explain the reality we live in. Reading “Health and Economic Crises,” I was quite often puzzled, thinking that maybe we are not living in the same world. It’s not that I disagree with all the ideas expressed, many of which I actually share. It’s just that I have the feeling there is somewhere a distortion which doesn’t fit with reality. Maybe facts and statistics are not exactly the same thing.
Let me put my questions the best I can. JT starts by saying that some authors have asserted that “the health consequences of crises depend on the policies applied by the government” and that “health is deteriorated by austerity policies.” To discuss these issues, JT says, one needs to define and measure “health.” Apparently, “the best way to measure health is to measure how frequent death is,” i.e., the important thing is mortality rates. That is where my doubts begin. Maybe this is the best way to measure health, but then it seems to me we are missing something. Is health just a question of life or death? If so, it seems to me we need to measure life too.
Capitalism is not a healthy system, not even a system for life, it’s a system quite well adapted to death and which actually produces death; it is even able to turn life and death into commodities. I perfectly understand and accept that during periods of capitalist expansion, working people’s health deteriorates, due to the terrible consequences of wage labor and exploitation. I also have no doubts about Marx’s idea that it’s the system itself which produces misery and disease. By the way, when Marx talks about long working hours causing a number of different diseases, we should remind ourselves that we have returned to a similar situation today—a recession during which fewer people work, but work longer hours, sometimes as long as in the 19th century. JT says that in general, “overtime and working hours diminish in recessions.” But in real society, this is not always true: today, most people who still have jobs work harder and longer hours, very often without pay (so that they are unaccounted for in statistics). That’s the situation generally, in countries from France to Greece or Portugal. The main reason people are forced to accept this situation, under modern exploitation, is fear.
The fact that stopping work is good for health is also a clear and obvious idea well worth underlining. No doubts on that either. That is what our own experience tells us, and what we fight for, as individuals or collectively.
We also agree, I suppose—or at least some of us do—that public policies are not enough to improve health. Most of the time, such policies just play a role in keeping people in good enough condition to continue being exploited. That is what’s known as “health.” Public health seems to exist to compensate for the fact that exploitation is bad for human beings. Having said that, I prefer living in a society where I can be taken care of in a hospital immediately if I break my knee, rather than suffering and waiting on a list for over a year to get a simple operation, as is the case in Portugal or Greece nowadays.
Statistics may well show that declines in overall mortality coincide with economic depressions. But I doubt we can conclude that recessions, in general, improve health! I wonder how statistics are produced, what people they take into consideration? For example, do they take into account the increasingly large numbers of unemployed, marginalized, or discouraged people who have fallen under the radar of economic statistics? Do they take into account the fact that many working people now go to work despite suffering and illness (which they cannot afford to treat), because they are afraid of losing their job?
Yes, I can agree that the crisis in the former socialist bloc, its transformation and the frightful social consequences and health problems, was a “special crisis.” But the current crisis of our societies also seems “special,” insofar as we are not experiencing a traditional business cycle crisis that lasts three or four years. This crisis seems to be longer, which means that we are only just beginning to see its effects. The social consequences for people’s lives, and particularly for their health, will become obvious only later. In Portugal, returning to my example, about a quarter of the population is now living below the poverty line (18 percent in 2009), many skip one meal a day, children are being fed at school (to the extent that schools are still open), not to mention the awful food people are forced to eat when they live in poverty. Also, how do we fit in the consequences of ecological destruction, which has actually accelerated with the recession? Is it possible to believe that this situation won’t in the long run have consequences for health?
The situation differs in societies where people were used to living in a welfare state, as in Europe, and in societies such as the U.S. In Europe, the attacks on the welfare state, public health services, and education, and the massive cuts in welfare benefits, together with rapid urbanization (primarily in southern Europe), leave the population increasingly vulnerable, with obvious effects on mental and physical health, which is all the more visible because it’s new.
As for suicides, JT’s statistics seem to me quite accurate. I disagree, however, that they are unrelated to the recession. Sure, there are other reasons for suicide; in Iceland or Finland, for instance, depression has been prevalent for many years. In Greece and Portugal, in contrast, suicide rates have risen very fast with the recession and austerity. I would treat this issue differently. Not statistically, but from the perspective of class struggle. Where people are losing hope and do not fight back, suicide is one option they consider. Where they are more ready to fight back, to struggle, as in Spain, suicide is less present. In a way, sliding into deep passivity and resignation is a form of suicide in our world of living-deaths.
While we’re on the subject of rates and statistics, how should we consider birth rates, which have fallen dramatically in the southern European countries? In Portugal, the birth rate dropped from more than 2 percent to less than 1 percent in only a few years. How can we relate that to the mortality rate? Could its decline be another indication of a dying society? If so, would it contradict the idea of a healthier society?
We surely agree that people are not doing very well these days! True, their life wasn’t great before either, during periods of capitalist expansion, when they had to work like mad; maybe the mortality rates were in fact higher. Now, maybe, people can live longer. But how much longer? And, if the crisis becomes permanent, under what conditions? How healthy will they still be? They may live longer, but in worse shape!
Besides figures, statistics, and rates, we could raise the issue of the meaning of life in this ugly system. Yes, I know, that is beyond the realm of “science” and statistics. But is it really? In fact, I see only one answer. To fight back, to oppose the system, is the only way to live in the world as it is presently organized.
Meanwhile, thanks for giving me the opportunity to think about all this stuff. It makes me feel healthier!
—A traveler in southern Europe
José Tapia replies: Feeling healthier or dying less—What is health? How to measure it?
Traveler (I will call my critic by that name and I will assume he is male) seems puzzled by the assertion that “the best way to measure health is to measure how frequent death is.” He adds that if that is the case, then something must be missing and it seems that we need to measure life too. Well, those who have investigated these issues have mostly been unable to find a better way to measure health than to measure death. Certainly, there are measures such as quality-adjusted life years (Q.A.L.Y.) and disability-adjusted life years (D.A.L.Y.), which are sometimes computed for the purpose of international or intertemporal comparisons. But these measurements “which measure life too” are very controversial, as they require us to assume that, for instance, living one year with blindness (or malaria, or depression) is equivalent to a percentage, say 80 percent, of living a totally healthy year. Therefore, for measuring the deterioration of population health, five persons becoming blind would be counted as suffering a health loss equivalent to that of one person dying one year in advance. Of course, percentages like these are arbitrary, can be arrived at only “by consensus” of experts, and are widely disputed. Attempts to add up disease and death in measures of population health that “measure life too” have thus only produced controversial indicators and unending arguments. This may puzzle those unfamiliar with the field, but that is the way it is. Life expectancy at birth is by far the less controversial way to measure health. But, unfortunately, is totally based on mortality rates.
Traveler says that capitalism is not a healthy system. Whether that is or is not the case largely depends on what we compare capitalism with. From the point of view of the survival of humans, other systems of economic organization were far unhealthier than capitalism. In primitive societies of hunter-gatherers cannibalism was common, human bones provide evidence that humans died at very young ages—often killed by other humans or animals—and life expectancy at birth was very low, just a few years. Things probably improved when agriculture appeared. In the large agricultural economies of the empires of antiquity, life expectancy was higher than in hunter-gatherer societies, but life expectancy was still much lower than today. During the Middle Ages, when the predominant economic organization was that of tribute regimes, populations often suffered major epidemics that could reduce them by half or more. Historical reports indicate, for instance, that in 1353 China suffered deleterious epidemics that in the Shansi region killed more than two-thirds of the population. At these times, life expectancy at birth could drop as low as 10 years or less. From the historical point of view, capitalism has been the economic system that has allowed world population to grow to the present 7.3 billion. This is because major epidemics have been eliminated, so that life expectancy at birth is now around 80 years in high-income countries and around 50 years in countries as poor as Chad or Niger. Life expectancy at birth was probably, in normal periods, below 30 in all regions of the world until a few centuries ago, and much lower in prehistoric times or in periods of famine and epidemics—which often appeared together. If capitalism continues to push human society against the limits of the natural world and toward another world war, the outcome could be a mortality crisis of unprecedented magnitude, but for the moment, fortunately, that has not happened. A society organized on the basis of egalitarian distribution and human cooperation in production might imply large gains in health, but for the moment, too, that is only a possibility.
Commenting on the idea that long working hours cause disease, Traveler asserts that in countries like France, Greece, or Portugal “today, most people who still have jobs work harder and longer hours, very often without pay.” The main reason for that would be fear. I agree that situations of high unemployment rates often force workers to accept both working longer hours and being paid at lower rates. That is a basic mechanism for the recovery of profitability during economic crises. However, Traveler asserts that today we may be in a situation in which some people work “as long as in the 19th century.” This seems to me quite an exaggeration. In the course of the 19th century the fight for a shorter working day produced important gains and, although things may have deteriorated recently in a number of countries, I do not think the situation is similar to that of the 19th century, when the working day was often 14, 15, or even more hours. In England in 1833 a Factory Act was passed limiting the working week to a maximum of 48 hours—but that was only for children aged 9 to 13. The fight for shortening the working day extended for decades, but the eight-hour day was a reality in many countries during most of the 20th century. On the other hand, statistics of recent decades show that working hours generally increase in expansions and decrease in recessions. O.E.C.D. data show that in general average annual working time (in hours per worker) was higher during the years before the crisis started. Thus annual hours per worker in Greece, Estonia, Portugal, the U.K., and France peaked between 2005 and 2008, and in 2012 were at lower levels than in 2005 – 06 (see figure); only in Spain was annual working time in 2012 at exactly the same level, 1686 hours, as in 2005. Workers are under management pressure to work more hours in every phase of the industrial cycle, but if collective bargaining requires workers to be paid overtime at a higher rate, then managers have a strong incentive to demand overtime only when the demand for the output is high, so that overtime is the first thing eliminated when demand starts slacking in the early phases of a recession. Then, if the recession deepens, before laying-off workers, managers prefer to reduce cost by demanding furlough days. All that of course is mediated by labor laws and regulations, and may change between countries. Furthermore, statistics on working hours may be biased by misreporting. In spite of all that, I believe that probably is a general law that working time per worker generally increases in expansions and decreases in recessions.
Traveler often refers to Portugal, which he considers the poorest country in Europe. However, that is only true in the context of Western Europe. Considering, for instance, average income as proxied by G.D.P. per capita in purchasing power parity units, the level of income per capita in Portugal in recent years is very similar to that of Greece, but about 50 percent greater than that of Bulgaria, twice that of Serbia, and three times that of Romania or Albania. Compared with its neighbor, Portugal’s G.D.P. per capita is about 80 percent that of Spain. In 2010 – 11 the literacy rate of the population aged 15 or over was 95.4 percent in Portugal, 97.3 percent in Greece, 97.7 percent in Spain, 96.8 percent in Albania, and 98.0 percent in Serbia. I could not get data on poverty for these countries, but I am quite positive that poverty rates in some of them are as high as or higher than in Portugal.
Traveler refers to the birth rate, which he says is at very low levels in Portugal. That is true, but the birth rate is also at comparably low levels in Germany, which has been to a large extent spared by the recent crisis. Suicide rates often rise during periods of economic recession at the same time that the unemployment rate grows. But after 2007 suicides rose very moderately in Portugal, and they are at much lower levels than in, say, France or Switzerland. Interestingly, compared with the levels in 2000 – 01 and in the 1990s, the suicide rate in Portugal doubled in 2002, and then remained high (see table). An aspect in which Portugal looks particularly bad among European nations is the very low percentage of people who self-assess health as good, a statistic that is reported by the European Office of W.H.O. Portugal is at the lowest levels with 49.1 percent, which is similar to 49.0 percent in Latvia, 51.9 percent in Lithuania, and 52.6 percent in Estonia, and quite below 67.2 percent in France, 71.8 percent in Spain, 71.0 percent in Denmark, 75.5 percent in Greece or 80.0 percent in Sweden. All these are figures are for 2010. However, to feel ill does not necessarily mean to have any major health problem. To a large extent it depends on culture, and also on temporary factors. In the case of Portugal, maybe Pessoa and the fado have something to do with this gloomy self-assessment; I do not know. There are no recent figures for the percentage of people self-assessing health as good in countries of the old U.S.S.R., but from the early to the late 1990s in Ukraine it went from more than 80 percent to less than 20 percent. At the same time there was a loss of life expectancy at birth in that country, but it was only from 69.7 to 67.8 years.
The world economic crisis that started at the end of the past decade has quite specific characteristics in European countries like Spain, Portugal, and Greece, where the recession has been particularly long and deep. But I do not agree with the idea that the world economy is now in a state of permanent crisis, or with Paul Krugman or Larry Summers, who assert that the perspective is one of long-term stagnation. I rather think that in the past three years the world economy has been in a very weak expansion. That could change rapidly and another major downturn could start anytime. Indeed, today’s newspapers report that recession is now official in Japan. For the moment, statistics show that population health as measured by mortality and life expectancy is not damaged by capitalist crises. Of course, population health and health care are different things. Governments in Europe are applying policies of destroying or commodifying the public systems of health care that have been in place for many years. Austerity has reduced health-care budgets in many countries and patients have to suffer long waiting lists, and spend less on medicines. Fortunately, people’s opposition to all that has been often enough to stop these plans. In quite a number of cases, however—not when you break your knee—less medicine and fewer medicines can be healthy; too many pharmaceuticals and medical procedures are indeed useless or harmful.
—José A. Tapia
ContributorJose A. Tapia
JOSE A. TAPIA is an Associate Professor of Politics at Drexel University, Philadelphia. His research has been published in Journal of Health Economics, the American Journal of Epidemiology, Social Science & Medicine, PNAS, and other journals.