Health and rapid economic change in the late twentieth century

Health and rapid economic change in the late twentiethcentury

Clyde Hertzman*, Arjumand Siddiqi

Department of Health Care and Epidemiology, University of British Columbia, Vancouver, BC, Canada V6T 1ZE

Abstract

Rapidly expanding economies, such as the post-war Tiger Economies, are associated with increasing health andrapidly contracting economies, such as Central and Eastern Europe in the early 1990s, are associated with declininghealth. In Central and Eastern Europe health decline in association with economic contraction has been mediated

by changes in income distribution and, also, by health-determining aspects of civil society. The nations of Centraland Eastern Europe are an example of swift economic and political transformation occurring concurrently witheconomic decline; with increasing disparity in income distributions; and with high levels of distrust in civil

institutions. Concurrent with these declines was a marked reduction in health status, described here in terms of lifeexpectancy. Conversely, the nations of Southeast Asia experienced rapid economic growth and increasing lifeexpectancies. Though data are scarce, the experience of the Tiger Economies appears to be one of economic growth;

a virtuous cycle of increased investment in education and housing; and increasing parity in income distributionbased upon a relatively equitable distribution of returns on education. 7 2000 Published by Elsevier Science Ltd.All rights reserved.

Keywords: Central and Eastern Europe; Tiger Economies; Income distribution; Health status; Life expectancy; Civil society

Introduction

This paper is concerned with the health e�ects of

rapid economic change, whether it be economic expan-sion or contraction, in whole societies. Our thesis isthat understanding the health e�ects of rapid economic

change requires understanding its e�ects upon otherdeterminants of health, in particular, income equalityand the function of civil society. To explore this, we

compare two groups of countries. The ®rst group,from Central and Eastern Europe (CEE), are anexample of rapid economic contraction. The second

group, the Tiger Economies of Asia (TE), are anexample of rapid economic expansion.If we assume that the relationship between health

and wealth found among the world's countries were®xed, then rapid economic expansion or contractionwould simply move a country along a pre-determined

functional relationship. This relationship has beendetermined, and can be described as follows:

Early in the twentieth century, life expectancy was

lowest among low income countries and highestamong high income countries. However, as the cen-

Social Science & Medicine 51 (2000) 809±819

0277-9536/00/$ - see front matter 7 2000 Published by Elsevier Science Ltd. All rights reserved.

PII: S0277-9536(00 )00062-9

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* Corresponding author. Tel.: +1-604-822-3002; fax: +1-

604-822-4994.

E-mail address: [email protected] (C. Hertz-

man).

tury unfolded the strongly positive correlationbetween health and wealth began to break down

among the wealthiest countries. In recent decadeseach of the world's richest nations has surpassed acritical threshold level of per capita income of ap-

proximately US$11,000 (1990) dollars. Above thisincome level, the health±wealth curve ¯attens out,such that further increases in per capita income are

associated with much smaller increases in healthstatus (World Bank, 1993). Yet, the strongly posi-tive association between health and wealth persists

among the world's poorer countries.

In other words, the argument goes, knowledge of asociety's per capita income at one point in time, and

its rate of economic growth or shrinkage over a givenperiod of time thereafter, should allow us to simplyplot its health trajectory along the health±wealth

curve.This approach, however, ignores two important con-

siderations. First, at any given level of national wealththere is a large degree of variability in the health status

of societies. This variability is due to a wide variety offactors operating at the national and civic level. Forinstance, among poor countries, education and inde-

pendence of women is a key determinant of betterhealth status (Caldwell, 1986). Among wealthycountries equality of income distribution (Wilkinson,

1992, 1996) and the quality of civil society functions(Kawachi, Kennedy, Lochner & Prothrow-Stith, 1997)are associated with better health status. This ®rst con-sideration leads to the second. If health is determined,

at the societal level, by complex factors related tonational wealth, but not simply determined by it, thenrapid economic change could lead to disruptions of

civil society in ways which would a�ect health otherthan through changes in wealth per se.

Health, civil society, and rapid economic expansion and

contraction

For each CEE and TE nation, per capita grossdomestic product (GDP) was used as a measure of

the size of the economy. In order to trend econ-omic changes over the past 50 years, various datasources were necessary, since a single complete

source could not be located. Data su�cient forcomparison purposes was not found for years prior

to the mid 1950s and after the early 1990s. Gender

strati®ed life expectancy data was also trended forthe two regions, as described below. Again, di�-culty was encountered due to incompleteness of

available data sources.Fig. 1 shows the trends in national wealth for the

CEE countries over time.1 From the late 1950s untilthe mid 1960s national di�erences in economic growthamong CEE countries were hard to detect, and their

per capita GDPs were below $1000 USD for eachnation. Starting in the mid-1960s, the region began asteady increase in per capita GDP. The CEE econom-

ies, however, were growing at di�ering rates and so, bythe late 1980s, large di�erences in national wealth were

apparent among them. Beginning in 1988, the regioncollectively experienced an abrupt halt to this morethan 20 year pattern of growth. The per capita gross

domestic product ®gures peaked in this year and sub-sequently declined (with the possible exception of theCzech Republic). Though the data for the period fol-

lowing the turmoil in this region is scarce, it appearsthat CEE is making a recovery, with increases in the

nations' per capita GDP after 1992. Thus, the periodof rapid economic decline occurred over the period1988±1992 for most CEE countries, but for Russia,

Ukraine, and Bulgaria, economic declines have contin-ued into the mid and late 1990s. The period of rapideconomic decline was also the period of rapid political

change; with the end of the Soviet period; the intro-duction of the triumvirate of free speech, parliamen-

tary democracy, and the free market; and thebreakdown in traditional trading relationships amongformer Warsaw Pact countries and within the Former

Soviet Union.Through the 1950s and much of the 1960s, the

TE of Southeast Asia resembled the CEE with

economic growth occurring on such a small startingGDP that the trends are barely detectable (Fig. 2).

Toward the end of the 1960s, these nations startedon a growth track which, on average, was muchstronger than the one in CEE, with some (such as

Japan and Hong Kong) experiencing more rapidgains than others (such as Taiwan and Korea). TheTE, for the most part, continued this growth pat-

tern at a very rapid pace from the late 1970sonward. By the late 1980s the TE were, on average,

twice or three times as large as the CEE economies.Moreover, during the period of economic decline inthe CEE, the TE continued to grow.

Female life expectancy in the CEE (Fig. 3)increased rapidly during the 1950s, largely in re-

sponse to rapid declines in infant mortality. Sincethat time and until the late 1980s there was a rela-tively steady increase, save a few inconsistencies in

the early 1970s and again in the early 1980s amongspeci®c countries. Subsequent to this period, during

1 The Soviet Union and CEE de®ne national income

according to net material product, which leaves out ser-

vices. Although this would make it di�cult to compare

with the TE the relevant comparison here is within a

country over time.

C. Hertzman, A. Siddiqi / Social Science & Medicine 51 (2000) 809±819810

Fig. 1. Gross domestic product per capita in CEE (Euromonitor International Inc., 1998/1999; National Bureau of Economic

Research, 1999; International Monetary Fund, 1998; World Bank, 1965±1997).

Fig. 2. Gross domestic product per capita in TE (Chinn, 1982; National Bureau of Economic Research, 1999; World Bank, 1965±

1997; International Monetary Fund, 1998).

C. Hertzman, A. Siddiqi / Social Science & Medicine 51 (2000) 809±819 811

Fig. 3. Female life expectancy in CEE (World Bank, 1965±1997; Watson, 1996; United Nations Children's Fund, 1998).

Fig. 4. Female life expectancy in TE (World Bank, 1965±1997; Watson, 1996; United Nations Children's Fund, 1998).


the period of rapid economic decline, female life ex-

pectancy in approximately half the countries also

underwent a decline. Among the TE (Fig. 4), female

life expectancy data shows an overall steady increase

from 1950 to mid-1990s. In the 1950s, 60s, and 70s

female life expectancies in the two regions were

similar. However, by the 1980s, life expectancies

among women in the TE had, on average, exceeded

those in CEE. By the mid-1990s the only TE whose

women's life expectancy was in the range of CEE

was Korea, which was also the TE with the most

modest economic performance in recent years.

The male life expectancy trend in CEE mirrors

that of its female counterpart (Fig. 5). The excep-

tion to this is that the ¯uctuations that occur are

markedly more dramatic for men than women.

Male life expectancy in CEE had increased at a

steady rate from the 1950s, through to the 1970s,

at which point the trend shows a ¯attening. In

1989, male life expectancy in CEE, like that of

women, experienced another decline which, in most

countries, continued through the mid 1990s. Male

life expectancy in the TE (Fig. 6) is also similar to

its female counterpart. The same pattern of contrast

between men in CEE and the TE over time is also

seen.

Table 1 shows the available Gini coe�cients for

CEE from the time of political and economic upheaval

in 1989 to present day.2 Across all countries, it is evi-

dent that the period of rapid economic contraction

was also a time of increasing income inequality. Unfor-

tunately, data from the TE is too scarce to say whether

or not sustained economic growth brought with it

increasing or decreasing income equality.

Table 2 shows an indicator of the functioning of

civil society, namely, trust in institutions. Compari-

son is drawn between Western Europe as a region

Fig. 5. Male life expectancy in CEE (World Bank, 1965±1997; Watson, 1996; United Nations Children's Fund, 1998).

2 The Gini is a commonly-used measure of income distri-

bution in societies. It is calculated on the basis of a ``Lor-

enz curve,'' which plots the cumulative portion of national

income received by families, from the lowest to the highest

income, against the fraction of the population consuming

that income. In a perfectly egalitarian society, the curve

would be a straight line, and is de®ned as a Gini of 0. In

a society where all income derives to one citizen, the

curve will go along the X-axis until the hundredth percen-

tile of income, and go up vertically from there. This

de®nes a Gini of 1.0. The Gini, then, is the area under

the straight line (perfectly egalitarian), left un®lled by the

Lorenz curve for a given country. Lower values mean

greater income equality. However, the Gini coe�cient does

not allow for the examination of income trends in any

speci®c segment of the income distribution. By way of

comparison the Gini coe�cient rose by 36% between 1979

and 1990 in Britain, during the Thatcher reforms

(Gottschalk & Smeeding, 1997).


and the nations of CEE. With respect to each insti-

tution, CEE shows markedly greater distrust (es-

pecially concerning parliamentary bodies and trade

unions, Soviet era or newly formed). Once again,

not enough data is available to make comparisons

with the TE, or, in this case, within CEE countries

over time. For instance, we cannot say for sure

whether or not civic a�liation in the CEE countries

has changed from the Soviet era to the present.

Nonetheless, the broad trends in life expectancy and

economic change in CEE and TE support the

notion that economic growth is associated with

increasing health. Furthermore, the data in Table 1

suggests that income equality may decrease under

conditions of economic contraction (although the

reverse cannot be inferred). The di�erences in civic

a�liation between Eastern and Western Europe are

also of interest (Table 2). These observations raise

two important questions: are increasing income

inequality and civic disa�liation inevitable with

economic contraction? Conversely, is declining

income inequality and increased civic a�liation

inevitable with economic expansion?

Table 3 shows the determinants of poor self-rated

health among a random sample survey of 1138 Rus-

sian adults, aged 35 and over, done in 1996. Insights

from Russia are signi®cant because it has had a deep

and prolonged economic crisis following the end of the

Soviet period and because health declines have been

greater there than anywhere else. The table shows that

Fig. 6. Male life expectancy in TE (World Bank, 1965±1997; Watson, 1996; United Nations Children's Fund, 1998).

Table 1

Gini coe�cients for Eastern Europe 1988 to presenta

Russia Ukraine Bulgaria Czech Slovak Hungary Romania Poland

1989 0.26 0.25 0.2 0.2 0.18 0.21 0.23 0.25

1990 0.24 ± ± 0.2 0.18 ± 0.23 0.19

1991 0.25 0.19 ± 0.19 0.18 0.29 0.24 0.23

1992 0.27 0.27 0.29 0.19 0.19 0.28 0.25 0.24

1993 ± ± 0.3 ± 0.2 ± ± ±

1994 ± ± ± 0.25 0.23 0.32 ± 0.32

1995 ± ± ± ± ± 0.32 ± 0.32

1996 0.46 0.4 0.28 0.26 ± 0.35 0.3 0.29

a Source: World Bank (1990±1997); United Nations (1996); United Nations Children's Fund (1993±1994).


poor self-rated health was independently associated

with factors in each of the economic environment, the

psychosocial environment and civil society. These fac-

tors were economic deprivation, low levels of edu-

cation, low levels of perceived control over life and

reliance on formal institutions.

Economic deprivation is based upon a 0 to 9 scale

re¯ecting the frequency with which the respondent's

family has trouble a�ording food, heat, and clothing.

A score of 0 means the family is never without these

necessities, while 9 means that the family goes often

without each of them. The relative risk for poor health

across the full scale is 2.85, which is approximately the

same as the e�ect size across the range of categories of

Table 2

Lack of trust in institutions of society, Western Europe vs CEE (in %)

Western Europea Bulgaria Czech Slovak Hungary Poland Romania Ukraine Russia

Church/religious organizations 17 53 48 35 36 39 19 37 49

Police 7 68 39 42 32 32 43 67 67

Civil service/servants 14 66 41 44 39 46 50 63 68

Military/army 17 27 33 26 29 19 13 45 32

Parliament/Duma 13 81 44 53 57 47 56 73 60

Trade unions 18 ± ± ± ± ± ± ± 66

Òld' unions 67 76 69 64 60 66 70

`New' unions 72 47 51 48 62 59 70

a Western Europe based upon the response ``no con®dence at all.'' All CEE countries, based upon the response ``do not trust''.

Source: Ashford and Timms (1992); Rose (1995a).

Table 3

Socioeconomic and psychosocial factors and poor self-rated health in Russia

Fully adjusteda

Sex Males 1.00

Females 1.20 (0.83±1.75)

Age Per 5 years 1.29 (1.21±1.37)��

Deprivation Per 1 unit 1.14 (1.08±1.21)��

Education Primary 1.00

Vocational 0.57 (0.36±0.91)�

Secondary 0.39 (0.24±0.63)��

University 0.40 (0.22±0.73)��

Control over life Per 1 SD 0.71 (0.60±0.84)��

Control over health Per 1 SD 0.86 (0.73±1.00)

Smoking No 1.00

Yes 1.29 (0.87±1.89)

Alcohol consumption Never 1.00

< 1�month 0.42 (0.29±0.61)��

1�month 0.47 (0.30±0.73)��

>1�month 0.28 (0.17±0.46)��

<1�week 0.99 (0.51±1.92)

Marital status Married 1.00

Single/divorced 1.14 (0.76±1.70)

Widowed 1.58 (1.03±2.43)�

Reaction to economic change Pro-market 1.00

Always positive 1.10 (0.58±2.09)

Always negative 1.40 (0.74±2.65)

Nostalgic 1.12 (0.64±1.97)

Types of social capital (on whom rely in problems) Self only 1.00

Informal only 1.08 (0.78±1.50)

Informal+formal 1.17 (0.48±2.84)

Formal only 2.03 (1.31±3.16)��

a Fully adjusted=adjusted for all other variables in the model. �p<0.05, ��p<0.01, ��p<0.001. Source: Bobak et al. (1998).


education. Large risks are also seen for those who per-ceive themselves to have a low level of control over

their daily life. The table also suggests that those whorely on formal institutions (employer, state, public or-ganizations, charities and church) to solve problems of

daily living have worse health status than those whorely on themselves, friends and relatives. This surpris-ing result suggests that the formal institutions of Rus-

sian society are in such crisis that reliance on them is alast resort for people.

Central and Eastern Europe

After 1989, the political and economic changeswhich occurred in CEE society amounted to the mostcomprehensive natural experiment in population-wide

stress imaginable, short of war and mass starvation.As mentioned above, per capita income of every transi-tional country fell in response to this rapid metamor-

phosis and all economies, bar Poland, lost theirrelative international position for this indicator ofeconomic prosperity (Kangas, 1999). Within four yearsof the onset of political change, real wages had fallen

signi®cantly; between 18 and 54% (UNICEF, 1994).This time period was also marked by high rates ofunemployment and in¯ation (Brainerd, 1997).

Political instability was also rampant in the regionfollowing the sudden switch to a free market economy.This change of guard, from Soviet-style communist

regimes to equally ``fundamentalist'' capitalist econ-omic approaches, occurred in much of the CEE, aphenomenon described as `shock therapy' (Sachs,

1994). The United Nations Development Programnoted `` . . .the fragility of the reform process . . . '' (Uni-ted Nations Development Program, 1996). There wasalso marked disruption of the social environment, as

demonstrated by 19±35% declines in crude marriagerates and reductions in pre-primary school enrollment(UNICEF, 1993). CEE also showed low levels of con-

trol over life and trust in institutions, factors indicatingminimal post materialism in these countries. This isconsistent with the theory that economically poor

countries tend to be concentrated on the provision oftangible goods, or, materialism (i.e. food, shelter etc.),in contrast with relatively wealthier nations, whosepost materialist focus tends more to be on aspects of

quality of life (Abramson & Inglehart, 1995). Accord-ing to sample surveys of ten countries in the region,conducted in the winter of 1993±94, between 20 and

53% of households reported that they could not copeeconomically; even when resources gleaned from theinformal economy were considered (Rose & Haerpfer,

1994; Rose, 1995a).At the same time, a population crisis in CEE

was in the making (Cornia & Paniccia, 1995). There

were dramatic increases in mortality among males

and females of working age. Among young males

aged 30±49, mortality rose as much as 70±80% in

Russia; 30±50% in Ukraine; and 10±20% in

Hungary, Bulgaria, and Romania. Among females,

mortality in the same age range rose 30±60% in

Russia; 20±30% in Ukraine; and more modestly in

Hungary, Bulgaria, and Romania (UNICEF, 1994).

During this time the primary causes of death, as

discussed below, are trauma and cardiovascular dis-

ease.

Why did these massive changes in health status

occur? Recent studies have demonstrated that the tra-

ditional risk factors that are associated with trauma

and CVD are not su�cient to explain these mortality

trends (Cornia & Paniccia, 1995). The leading possi-

bility is that the transformation in Central and Eastern

Europe created conditions of loss of control over life,

economic deprivation, and social isolation which, in

and of themselves, undermined the health status of the

population. This conclusion is supported by two lines

of reasoning. The ®rst shows that none of the other

plausible explanations stand up to critical scrutiny.

The second shows how socioeconomic and psychoso-

cial conditions per se can in¯uence health status to a

profound degree.

With regard to the ®rst line of reasoning, the

alternative plausible explanations are that changes in

diet, smoking, drinking, environmental pollution, and/

or the quality of health care services occurred with the

political and economic changes, and caused the decline

in health status. How do these explanations fall short?

. The principal causes of death that have contributed

to increased mortality since 1989: injuries and heart

disease, are overwhelmingly `ìncidence-driven.''

Changes in smoking and diet are not likely to have

had their impact on health status so quickly, since

their e�ects require a relatively long latent period. In

other words, the risk of death or disability is primar-

ily determined by the fact that the heart attack or

injury event occurred and not by the medical care

provided after the incident event.

. Alcohol consumption has been reported to have

increased in Russia and other Newly Independent

States and some investigators have claimed that this

increase is the primary explanation for the life ex-

pectancy decline in the region (Leon et al., 1997).

However, large mortality increases have occurred

for all major causes of death, excluding cancer. This

goes far beyond that which can be attributed,

directly or indirectly, to alcohol.

. Pollution, if anything, has declined across the region

since 1989, as many polluting industries have shut

down (Hertzman, Kelly & Bobak, 1996). In relation

to the direct, toxic e�ects of pollution the conclusion


that there are strict upper limits to the contribution

of pollution to the life expectancy gap is similarly

convincing.

These negatives, however, do not make socioeconomic

and psychosocial conditions per se the principal expla-

nation simply by default. The paragraphs below pre-

sent the second line of reasoning; detailing how the

socioeconomic and psychosocial environment (SEP)

can a�ect health status within countries.

The SEP conditions which determine health are

found at three levels of aggregation in society. At the

broadest (macro) level of aggregation are state factors,

in particular, national wealth, income distribution,

degree of industrialization and urbanization, level of

unemployment, and the structure of opportunity cre-

ated by history, geography, and fortune which support

or undermine health and well-being. At the intermedi-

ate (meso) level, there is the quality of civil society;

that is, those features of social organization, such as

institutional responsiveness, social trust, and social

cohesion, which facilitate or impede coordination and

cooperation for mutual bene®t (Putnam, 1993) and, in

so doing, exaggerate or bu�er the stresses of daily

existence. At the ``micro'' level, there is the intimate

realm of the family and the personal support network.

These three levels of social aggregation are intersected

by time, in the form of the individual life course. What

emerges is a lifelong interplay between the cognitive,

behavioral, and emotional coping skills and responses

of the developing individual, on the one hand, and the

SEP conditions as they present themselves at the inti-

mate, civic, and state level, on the other.

To varying degrees in each country in CEE, the

image which best describes the relationship between

the three levels of social aggregation, over the long

term, has been that of an ``hourglass'' (Rose, 1995b).

This suggests a society with an elite at the top which

controls the available economic and political struc-

tures. Furthermore the model suggests a narrowing in

the middle; a civil society whose capacity to bu�er the

stresses of daily living is weak, leaving the average per-

son vulnerable. At the bottom of the hourglass, there

are those who have an overwhelming need to rely on

the intimate realm of family and informal social sup-

ports to compensate for a lack of support structures at

the higher levels of social aggregation. The data in

Tables 2 and 3 are consistent with this interpretation.

Before the political changes of 1989, the relationship

between the top and bottom of the hourglass was

thought to be stable, with a modicum of mutual obli-

gation between the state and the individual. After

1989, the twin ideologies of individualism and freemarket gave license to those who had in¯uence at the

highest levels of society to abandon their responsibil-ities. Evidence of this is the polarization of the labourmarket, with a decrease in the proportion of the popu-

lation who were economically active simultaneous withan increase in wages for those who remained active(Forster & Toth, 1998). This is re¯ected in the increase

in Gini coe�cients described earlier in this paper.The character of the variations in mortality, by mar-

ital status, country, and age ®t this explanation reason-

ably well. The hourglass society image, when broughttogether with the ``three levels of social aggregation''model of the determinants of health, predict that thosewith the weakest social support systems will be most

vulnerable. This is consistent with other ®ndings (Wat-son, 1996) that single people were more vulnerable todeclines in health status than married people during

the political transition. Abramson and Inglehart (1995)also support this thesis through their ®ndings thatthose with the availability of formal social capital only

were signi®cantly more likely to rate themselves ashaving poor health status. Moreover, those in earlyand middle adulthood, who are dependent on civil so-

ciety functions to earn a living and support families,may well be more vulnerable in the short run than thevery young and the very old; whose well-beingdepends, to a greater extent, on the intimate realm of

the family.

The Tiger economies

Japan began experiencing high growth rates in 1965,characterized by high gross national product, low in-¯ation and low unemployment rates (Marmot &Smith, 1989). This prosperity has continued until well

into the 1990s, as demonstrated by the increasing percapita gross domestic product (Fig. 2).3 Despite thelack of comparable Gini coe�cient data for the Tiger

economies, there is evidence that throughout thisperiod of growth Japan managed to maintain relativeequality in income distribution. In fact, in 1979, World

Bank statistics show that the proportion of incomereceived by the lowest earning one-®fth of the popu-lation was the highest of any reporting country (Mar-mot & Smith, 1989). In Taiwan, the Gini coe�cient

dropped by 50% (from 0.56 to 0.28) between 1953 and1976; during which time GNP per capita rose nearlysix-fold (Chiang, 1999). Hong Kong and Singapore

also showed simultaneous increases in both the size ofthe economy and income equality (United NationsDevelopment Program, 1996). The Tiger economies,

taken together, are a bona ®de example of the theorythat `` . . . inequality is not a necessary ingredient forsuccess . . . '' (Marmot & Smith, 1989).

3 This section does not include the period during and after

the `Àsian crash'' of 1998.


Policies adopted by governments of the TE pro-moted sharing of economic growth across the popu-

lation (Birdsall, Ross & Sabot, 1994). In Korea,Taiwan, and Singapore leaders o�ered land and hous-ing reform, as well as an emphasis on basic education,

to ensure support from working class and other non-elite groups. This, in turn, ensured that all groups inthe population bene®ted from economic growth. The

experience of the TE raises the possibility that edu-cation can contribute to economic growth; economicgrowth contribute to investment in education; and edu-

cation contribute to reductions in income inequalitywhich in turn can stimulate further educational invest-ments.The stimulus that education investments gave to

economic growth was also augmented by the exportorientation of the TE and the resulting labor and skilldemanding growth paths they followed. Birdsall et al.

(1994) also argues that this relative parity apparent inthe Tiger economies in itself has contributed to thelevels of growth seen there. Birdsall's hypothesis is as

follows: the comparatively secure economic outlook ofthe poorer people in the region has allowed them toset aside savings and make investments, in turn contri-

buting to the political and macroeconomic stability ofthe region. From the standpoint of the determinants ofhealth, there is a parallel story. Economic growth ac-companied by decreasing income disparities and

increasing levels of education, can be expected tostrengthen the status of the determinants of health intwo of the three levels of social aggregation identi®ed

above (macro and meso), as well as the life coursedimension.

Conclusion

This paper supports the hypothesis that rapid econ-omic change a�ects population health. Rapidly

expanding economies are associated with increasinghealth and rapidly contracting economies are associ-ated with declining health. In CEE the relationship

between economic decline and health has beenmediated by SEP factors, speci®cally income distri-bution and quality of civil society. In CEE swift trans-formation of the economic and political systems,

concurrent with economic decline, came with increas-ing disparity in income distributions and high levels ofdistrust in civil institutions. Concurrent with these

declines was a marked reduction in health status,described here in terms of life expectancy. Conversely,the nations of Southeast Asia experienced rapid econ-

omic growth and increasing life expectancies. Thoughdata were scarce, the literature supports the notionthat this growth was accompanied by a virtuous cycle

of increased investment in education and housing, rela-tive equality in income distribution.

Health status at the national level is associated withnational income, income distribution, and perceivedquality of civil society and psychosocial environment.

Economic growth, income equality, high levels of civica�liation and positive psychosocial conditions are allindependently associated with good health status.

However, the relationships among these factors areless clear. The experience of CEE has been for econ-omic decline and increasing income inequality to occur

together, yet in most industrialized countries the ex-perience during the 1980s was of increases in bothnational income and level of income inequality.Although we suspect that increasing civic a�liation is

associated with increasing income equality, and thateach reinforces the other, we have no direct evidenceof this, since the necessary prospective studies have not

been done. The clearest conclusion from this paper isthat the health impacts of rapid economic growth ordecline should not be analyzed in isolation from

changes in income distribution, civic a�liation, andpsychosocial living conditions which may well takeplace at the same time.

References

Abramson, P. R., & Inglehart, R. (1995). Value change in a

global perspective. Ann Arbor, MI: The University of

Michigan Press.

Ashford, S., & Timms, N. (1992). What Europe thinks: A

study of Western European values. Dartmouth, VT:

Dartmouth.

Birdsall, N., Ross, D., Sabot, R. (1994). Inequality and

growth reconsidered. Paper presented at the American

Economic Association, Boston.

Bobak, M., Chenet, L., Hertzman, C., Leon, D., McKee, M.,

Marmot, M., Pikhart, H., Rose, R., & Shkolnikov, V.

(1998). Studies in public policy: Surveying the health of

Russians. Glasgow: Cambridge University Press.

Brainerd, E. (1997). Luxembourg income study. Working

Paper Series: Women in transition: Changes in gender

wage di�erentials in Eastern Europe and the former Soviet

Union. Center for the Study of Population, Poverty and

Public Policy/International Networks for Studies in

Technology, Environment, Alternatives, Development,

Di�erdange, Luxembourg.

Caldwell, J. C. (1986). Routes to low mortality in poor

countries. Population and Development Review, 12, 171±

220.

Chiang, T. (1999). Economic transition and changing relation

between income inequality and mortality in Taiwan: re-

gression analysis. British Medical Journal, 319, 1162±1165.

Chinn, D. L. (1982). Growth, equity and gini coe�cients: The

case of Taiwan. Economic Development and Social Change,

30(4), 871±876 July.

Cornia, A., Paniccia, R. (1995). The demographic impact of


sudden impoverishment: Eastern Europe during the 1989±

1994 transition. Innocenti Occasional Paper Ð Economic

Policy Series, Number 49. UNICEF.

Euromonitor International Inc (1998/1999). World economic

factbook (6th ed.).

Forster, M. F., Toth, I. G. (1998). Luxembourg income

study, Working Paper Series: The e�ects of changing

labour markets and social policies on income inequality

and poverty: Hungary and other Visegrad countries com-

pared. Center for the Study of Population, Poverty and

Public Policy/International Networks for Studies in

Technology, Environment, Alternatives, Development,

Di�erdange, Luxembourg.

Gottschalk, P., & Smeeding, T. M. (1997). Luxembourg

income study Working Paper Series. In Empirical evidence

on income inequality in industrialized countries. New York:

Syracuse University.

Hertzman, C., Kelly, S., & Bobak, M. (1996). East±west life

expectancy gap in Europe: environmental and non-en-

vironmental determinants. In NATO ASI Series 19(2).

London: Kluwer Academic.

International Monetary Fund. (1998). Economic outlook.

Kangas, O. (1999). Luxembourg income study, Working

Paper Series: Social policy and transitional countries: A

comparison of institutions and their consequences. Center

for the Study of Population, Poverty and Public Policy/

International Networks for Studies in Technology,

Environment, Alternatives, Development, Di�erdange,

Luxembourg.

Kawachi, I., Kennedy, B. P., Lochner, K., & Prothrow-Stith,

D. (1997). Social capital, income inequality, and mortality.

American Journal of Public Health, 87, 1491±1498.

Leon, D. A., Chenet, L., Shkolnikov, V. M., Zakharov, S.,

Shapiro, J., Rakhmanova, G., Vassin, S., & McKee, M.

(1997). Huge variation in Russian mortality rates 1984±94:

artefact, alcohol, or what? The Lancet, 350, 383±388.

Marmot, M. G., & Smith, G. D. (1989). Why are the

Japanese living longer? British Medical Journal, 299, 1547±

1551.

National Bureau of Economic Research. (1999). www.nber.-

org/pwt56.html.

Putnam, R. D. (1993). Making democracy work: civic tra-

ditions in modern Italy. Princteon, NJ: Princeton

University Press.

Rose, R. (1995a). Studies in public policy: New Russia barom-

eter IV: survey results. Centre for the Study of Public

Policy, University of Strathclyde.

Rose, R. (1995b). Russia as an hour-glass society: A consti-

tution without citizens. East European Constitutional

Review, 4(3), 34±42.

Rose, R., & Haerpfer, C. (1994). Studies in public policy: New

democracies barometer III: Learning from what is happen-

ing. Glasgow: Cambridge University Press.

Sachs, J. D. (1994). Russia's struggle with stabilization:

Conceptual issues and evidence. In Proceedings of the

World Bank Annual Conference on Development Economics

1994. Washington, DC: The World Bank.

United Nations Children's Fund. (1993). Public policy and

social conditions, regional monitoring report No. 1.

UNICEF International Child Development Centre,

Florence, Italy.

United Nations Children's Fund. (1994). Crisis in mortality,

health and nutrition, economies in transition studies: re-

gional monitoring report No. 2. UNICEF International

Child Development Centre, Florence, Italy.

United Nations Children's Fund. (1998). Education for all?

Regional monitoring project No. 5. UNICEF

International Child Development Centre, Florence, Italy.

United Nations Development Program (1996). Human devel-

opment report. New York: Oxford University Press.

Watson, P. (1996). Marriage and mortality in Eastern

Europe. In C. Hertzman, S. Kelly, & M. Bobak, East±

west life expectancy gap in Europe: Environmental and non-

environmental determinants. NATO ASI Series 19(2) (pp.

143±160). London: Kluwer Academic Publishers.

Wilkinson, R. G. (1992). Income distribution and life expect-

ancy. British Medical Journal, 304, 165±168.

Wilkinson, R. G. (1996). Unhealthy societies: The a�ictions of

inequality. London: Routledge.

World Bank (1965±1997). World development reports. New

York: Oxford University Press.


Documents

Health and rapid economic change in the late twentieth century