Can wealthy societies maintain their health status while consuming less of the world's "photosynthetic resources"? This may seem like an esoteric question, yet Canada has recently ratified the Kyoto Accord. In order to meet its commitments under the Accord, Canada will need to reduce emissions of carbon dioxide by approximately 20% over the next decade. Since carbon dioxide is the end product of consumption of "photosynthetic resources" the question is de facto irresistible.
In the modern world, health, wealth, and consumption tend to occur together. Increasing per capita income among countries tends to be associated with increasing longevity. Early in this century the relationship was simple: life expectancy was longer in countries with higher per capita incomes. However, in recent decades the relationship between health and wealth has become more complex as rich nations have grown richer. The specific character of this complexity forms a basis for a more encouraging answer to the question posed above.
When longevity and national income curves are plotted together on a single graph, the cause for optimism can be seen in the changing character of the curves throughout the twentieth century. Figure 1 shows that, in 1900, the relationship between increasing national health and wealth was nearly linear. Wealthier meant healthier. But throughout the twentieth century the strength of this association increasingly broke down. By 1960, the slope of the health-wealth curve had flattened at the "rich end," such that variations in national income per capita were no longer strongly associated with further increases in life expectancy. By 1990 all the world's wealthiest nations (those belonging to the Organization of Economic Cooperation and Development) found themselves on this "flat of the curve" (World Bank 1993). At the same time, the traditional monotonic relationship between health and wealth persisted among the world's poorer countries; a pattern referred to here as the "steep incline", to distinguish it from the "flat of the curve".
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There are several ways to interpret these trends. One of the simplest is to assert that the material factors that limit health status in poor societies, such as food, clothing, shelter and clean water, become relatively unimportant determinants of health when national income reaches a certain level. This is intuitively appealing because there is such a thing as a sufficient amount of food, clothing, shelter, and clean water, beyond which further consumption should not lead to further health benefit. It may be pleasant to have better food, clothing and shelter, but they would not necessarily confer additional health benefits.
One simple conclusion, from the standpoint of economic development and health, is that poorer countries' attempting to match the rich, and reach the flat of the curve, is an essentially benign objective. In other words, the relationship between healthy and wealthy countries and poor and unhealthy countries ought to be one of imitation of the former by the latter. This interpretation assumes that economic growth, traditionally defined, is a laudable objective regardless of the forms that it takes. But this view is challenged by evidence that shows how differently rich and poor nations appropriate global photosynthetic resources. This is best represented in the calculation of the "ecological footprint", which is a measure of the area of the Earth's surface appropriated for its use by a given population in a given year (Wackernagel 1995).
Consumption of ecologically productive land (that is, land appropriated for energy, agriculture, and forest products as well as the area of the built environment per se) has grown rapidly across the globe in recent decades. Between 1950 and 1990, the appropriation of ecologically productive land by the worlds' richest countries increased from approximately 2 hectares to between 4 and 6 hectares per capita. Over the same time period, the global supply of ecoproductive land declined from approximately 3.6 hectares to 1.7 hectares per capita, primarily as a result of population growth. In other words, during the last half of the twentieth century the fraction of the world's ecoproductive resources appropriated by the world's richest countries has exceeded a level of global sustainability. The world's poorest nations have little room to increase consumption of those goods and services derived from ecologically productive land. To achieve equivalent levels of consumption, the planet Earth would need to appropriate at least two more planets' worth of ecoproductive land for the use of the developing world (Wackernagel, 1995). This is clearly an impossible dream.
This perspective sheds new light on the relationship between the health and wealth of nations. To begin with, the seemingly benign construct of per capita income should be replaced in international comparisons with more stringent measures of ecologically productive land appropriation. Calculations of the size of various countries' ecological footprints have been carried out for the year 1993 (Wackernagel 1997). Figure 2 shows the relationship between life expectancy for 1993, or nearest year, by country, in relation to its ecological footprint. As ecological footprints rise from zero, life expectancy increases rapidly. Once again, however, there is a flattening of the curve wherein the vast differences in the size of the world's richest countries' ecological footprints do not correlate with further increases in life expectancy. Indeed, there are no improvements in life expectancy, on average, above an ecological footprint of four hectares per capita. Indeed, average life expectancies in excess of 75 years are compatible with ecological footprints of less than 3 hectares per capita.
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When this observation is combined with the fact of limited global resources, the relationship between countries on the steep incline and those on the flat of the health-wealth curve is transformed. The flat of the curve no longer seems benign, but begins to look as though it exists at the expense of the steep incline. This, in turn, transforms the definition of success in national development and health. The most successful group of countries are those that maximize their health status while limiting their consumption. From the standpoint of global citizenship, these are the countries found at the left end of the flat of the curve, where the world's best health status coexists with the minimum appropriation of photosynthetic resources. Those countries found further to the right are increasingly inefficient producers of health that, through competition for global resources, may well be limiting the health chances of countries on the steep incline.
The prospect of richer countries playing the role of a global consumer to the poorer countries' global supplier raises obvious ethical issues, but a realist might suppose that these will not be decisive in determining the behaviour of nations in the future.
If success were measured by the ratio of life years produced to ecoproductive land consumed, the world's healthiest country would not be found on the flat of the curve. It would be Costa Rica. By 1991 it delivered a life expectancy of seventy-six years to its citizens, compared with an average of seventy-seven years for the world's twenty-two richest countries. This was accomplished with a national income of $1850 US per capita, and an ecological footprint of 2.5 hectares per capita compared with an average of $21,050 US, and an average ecological footprint of greater than 6 hectares per capita (Wackernagel 1995), for the twenty-two richest nations. In other words, Costa Rica would be found up, and to the left hand corner, of both Figures 1 and 2.
Costa Rica is not the only poor, low-consuming society with world-class longevity, and recognition of this group of societies is not new. These countries are characterized by high levels of literacy, independence among the female population, and high levels of spending on education and welfare (Caldwell 1986), as well as strong civic cultures, compared with other countries in their income bracket. (Heller 2000).
The characteristics of poor but healthy societies may be useful to other developing countries striving to make the best use of scarce resources, but this knowledge provides little help to wealthy societies that, over time, must reduce their current appropriation of global ecoproductive resources to make room for others. The fact that health and low appropriation of ecoproductive resources are compatible states does not mean that we know how to get there from where we currently are. What will happen if the developing world decides that the products of ecoproductive land that are currently being exported to the developed world for cash ought to stay where they are? This circumstance raises an important question: can wealthy societies maintain their health status while making a transition to lower consumers of the world's ecologically productive resources?
This question forces us to envision the developmental pathway from how we live now to how it might look under conditions of globally sustainable consumption. The flat of the curve, and the existence of countries like Costa Rica, demonstrate that lower levels of consumption are compatible with high levels of health status. What is at issue is the following: can the highest consuming societies successfully become more like a Costa Rica in terms of consumption patterns without undermining social stability and sharply increasing inequality in the socioeconomic domain? To answer this question, we need to consider much more carefully the determinants of health in human societies.
UNDERSTANDING THE DETERMINANTS OF HEALTH IN HUMAN SOCIETIES
Thomas McKeown (1979) showed that the precipitous decline in mortality from infectious diseases such as tuberculosis during the past century was not due to clinically effective vaccinations and antibiotic treatments. These diseases had been the major causes of mortality for centuries, yet effective clinical prevention and treatment interventions were developed and implemented after approximately 90 per cent of the historical decline in mortality had already occurred. Thus, in direct contradiction to received wisdom, the vaccine and antibiotic revolution played a rather minor role in lengthening human life expectancies in Western Europe, North America, Japan, and other wealthy countries.
Historically, the principal factors responsible for increasing life expectancy from less than fifty years to more than seventy years were found outside the health care system as traditionally defined, in the broader social/economic environment: improvements in housing, water supply, pollution control, nutrition, child spacing, working conditions, education, and a wide range of psychosocial factors which are thought to improve as societies become more prosperous, tolerant, democratic and inclusive. Some of these improvements were part of conscious efforts to improve the health of the population, and others not.
We now understand that factors that influence health are found at three levels of aggregation in society. At the broadest level of aggregation are those related to the state and the socioeconomic environment, in particular, national wealth, income distribution and social transfers, degree of industrialization and urbanization, level of unemployment, and the structure of opportunity created by history, geography, and fortune. At the intermediate 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 benefit (Putnam 1993) and, in so doing, exaggerate or buffer the stresses of daily existence. Finally, at the "micro" level, there is the intimate realm of the family and the personal support network.
This conception is illustrated in Figure 3, wherein society is represented by three concentric circles, forming a bull's eye, that stand for the clusters of determinants of health and well-being at the three levels of social aggregation described above. An arrow is piercing the bull's eye, which represents the individual life course. Health in human societies is "determined" by the interplay between the cognitive, social-emotional-behavioural, and physical development of each member of society, at each stage in the life course, and the day-to-day conditions of life that they encounter at the intimate, civic, and state level, as they go through life. The healthfulness of human society is the sum of these interactions across all members of society. Herein, this conjunction is referred to as "lived experience."
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GRADIENTS: THE LINK BETWEEN LIVED EXPERIENCE, CONSUMPTION AND HEALTH
Lived experience expresses itself in health status through a phenomenon known as the "gradient effect", wherein health status increases in a stepwise fashion from the lowest to highest socioeconomic strata of society. This gradient effect has been found in all wealthy societies, and it is found regardless of whether income, education, occupation or a combination of these measures is used to define socioeconomic status. There are four aspects of the gradient that point to lived experience as the basis of causation:
* the gradient cannot be explained away by reverse causation or differential mobility.
* the gradient effect is evident for virtually all of the major diseases that affect health and well-being in our society.
* as the major diseases have changed over time, the gradient effect has replicated itself on the new diseases as they have emerged.
* the gradient effect exists across the entire life course. It is apparent early in life in relation to infant mortality and low birth weight. Next, it is found in physical, cognitive and behavioral development, and has been measured as (modifiable) socioeconomic inequalities in readiness for school. During early adulthood the gradient emerges for mental health status, obesity, and limiting longstanding illnesses. By the fifth decade of life, there is a gradient in relation to the major causes of morbidity and mortality. In other words, the gradient represents a "causal" relationship between lived experience and health over the life course. The characteristics of the gradient point to the existence of fundamental biological processes connecting social circumstances to human resilience and vulnerability to disease, and strongly suggest a role for early child development in the process (Hertzman 2000).
The principal significance of the gradient for this discussion is that gradients appear to "flatten up." Those societies that produce the least inequality in health and human development across the socioeconomic spectrum have the highest average levels of health and development (see Figure 4). "Raising the bottom" of the socioeconomic spectrum does not "lower the top;" a fundamental challenge to the folk wisdom surrounding economic models currently in vogue.
[FIGURE 4 OMITTED]
These would predict that reductions in societal inequalities for those at the low end of the socioeconomic spectrum could only occur at the expense of those at the upper end. In other words, population health reminds us, first and foremost, that we are a social species, and our health and development depend upon the quality of the social environments where we grow up, live, and work.
An optimist might see these findings as evidence supporting the view that wealthy societies can maintain or improve their health status irrespective of income level and presumably, their level of consumption, by addressing equity issues. In that claim the optimists would be supported by the data in Table 1 below. It builds upon Figure 4 and suggests that, in wealthy societies, health equality is not purchased with a large ecological footprint. If anything, the reverse may better characterize the pattern.
The optimist would conclude that a healthy and sustainable society is achievable in any society committed to simultaneously reducing health inequalities and the consumption of photosynthetic resources. This would be a case of premature optimism. Consider, for example, some rough calculations that have been made about the size of the ecological footprint of different classes of Canadian citizens. The rich leave a much larger footprint than the poor. Professional couples with two cars and no children leave a footprint that is approximately three times as large as an average-income Canadian family, and four times as large as a family living on social assistance. Indeed, consumption among those on social assistance approaches a level that is globally sustainable (Wackernagel 1993). Unfortunately, the health status of such families is not as good as those who consume more. Those families in the lower one-fifth of the Canadian income spectrum have life expectancies approximately six years shorter for men and two years shorter for women than those with the highest one-fifth of income (Wilkins 1992). When one considers healthy life expectancy, by removing from consideration those periods of life in which individuals are disabled, the differences across the income spectrum increase. In both sexes, healthy life expectancy is approximately 10 years lower among those in the lowest one-fifth of the income spectrum compared with those in the highest one-fifth (Wilkins 1992).
Canadians who are consuming at a globally sustainable level appear to pay a price in terms of their health; a price not paid by those in places like Costa Rica who consume at the same or lower levels. It is unlikely that these international differences are tied to the material advantages of consumption. The most likely explanation is that individuals consuming at a globally sustainable level in a country like Costa Rica have, on average, higher social status within that country than their counterparts consuming at the same level in Canada. In the absence of further evidence, consideration should be given to the prospect that trying to drive down the consumption of the wealthy to the level of those whose consumption is globally sustainable would disrupt society in ways that could well drive down the health status of the whole population.
CENTRAL AND EASTERN EUROPE: A CAUTIONARY TALE
Are there natural experiments available that might be informative about the pitfalls of reductions in consumption across societies as a whole? It is true that acute reductions in consumption during famine are a threat to life and limb, but no one would suggest that episodes of starvation share important characteristics with the problem at hand. More relevant are the experiences of middle-income societies where purchasing power has been sharply curtailed, but where outright starvation has not resulted.
The best documented of these is the experience of Central and Eastern Europe since 1989. Within three years of the sudden political and economic changes, real wages in every country of the former Warsaw Pact fell between 15 and 35 percent (UNICEF 1993). These changes were accompanied by increases in the proportion of household income being spent on food in some countries in the region. Average per capita consumption of meat, fish and dairy products declined in these countries, with an accompanying decline in the size of the ecological footprint. At the same time there was marked disruption of the social environment, as demonstrated by declines between 19 and 35 percent in crude marriage rates and more modest reductions in pre-primary school enrollment. In all cases, life expectancy showed an immediate decline, driven by increased mortality among adults (especially men) of working age.
After an initial period of shock, however, the countries of Central and Eastern Europe divided into three groups. The successful societies (Czech, Poland, Slovakia, and Slovenia) re-established trajectories of health gain such that, by the end of the 1990s, they had improved over their position over 1989 (Table 2). The second group of societies "broke even" in health status terms within a decade of the beginning of transition (Table 3). Finally, there were the failures (Table 4). In these societies, mostly former Soviet Republics, the initial decline in health status was followed by a continuing decline throughout the 1990s, leading to truly remarkable excess mortality. For instance, in Russia the excess mortality over the decade 1989-1999 has been estimated at greater than 4 million (Cornia 2000). It is vital to understand why some societies handled the disruption with relative ease while others collapsed, because the transformation of Central and Eastern Europe is the world's natural experiment that comes closest to the scenario of a forced reduction in the ecological footprint.
Tables 5-8 present a case study comparing one society that succeeded in the transition (Czech) to another that failed (Russia). Table 5 shows the dramatic differences in age-specific patterns of mortality between the two countries, emphasizing the particular importance of the working age population as being most sensitive to the transition. This is an unusual pattern; suggesting that the stresses of transition fell mostly on those participating in the workforce and supporting dependents but not on those typically at greatest biological risk at the beginning and end of the life course. Table 5 also shows a remarkable difference in fertility patterns between the two societies. Whereas in Czech childbirth was delayed and teenage childbirth rates declined during the transition, quite the opposite happened in Russia. The Russian pattern, in particular, suggests a breakdown in social discipline not apparent in Czech.
Table 6 continues the theme of social disruption, showing steep declines in kindergarten enrollment, and huge rises in orphans and in sentencing rates in Russia not seen in Czech. At the same time, the economic recovery in Czech was not matched in Russia. Table 6 shows that, in Russia, the 1990s brought a precipitous decline in real wages and GDE Perhaps of greatest significance, the Gini coefficient of income inequality rose in both countries, as one would expect in a transition to a capitalist style economy. Yet, the differences between the countries are much more impressive than the similarities. By the late 1990s the level of income inequality in Czech was still at the level of the most egalitarian members of the OECD. In contrast, the rise in Russia took it from one of the most egalitarian societies in the world from the standpoint of income distribution, to one of the least, in less than ten years.
Table 7 emphasizes how different the management of economic transition and the experience of labour market participation has been in the two societies. In Russia, privatization was carried out as a fire sale; wages frequently went unpaid; and a huge gap opened up between minimum and average wages. Moreover, vast numbers of workers began drifting around the country in search of the means of economic survival. In Czech, privatization was conducted in a slow, deliberate manner and produced none of the other stresses and disruptions found in Russia. Finally, Table 8 shows the differences in trust for key institutions of society. Most significant is the ratio of trust for civil institutions versus the military. These differences contrast a functioning civil society (Czech) from one in which civil institutions have either been discredited or have not been creditable from the outset.
Thus, the resource rich, land rich society failed in its transition while the landlocked, land poor, resource poor society succeeded. Although this may seem like a startling outcome, it shows the same patterns as Cornell's studies (Cornell 2000) of economically successful versus failed Aboriginal communities in the United States and Chandler's work on the determinants of high and low suicide rates in British Columbia Aboriginal communities (Chandler 1998). In each of these cases, the success factors were not related to land, resources, and consumption. Instead, some combination of cultural continuity, strong civic community, high levels of formal and informal social trust, and high levels of affiliation to social institutions differentiated success from failure.
Wealthy societies consume too much of the world's resources, and need to cut back. In principal, this can be done without sacrificing human health. There are examples of societies that consume at globally sustainable levels and maintain a health status that is similar to ours. We know that the principal determinants of health in wealthy societies reside, broadly speaking, in the social environment. But do we know how to reduce our levels of consumption without sacrificing those aspects of our society that are health-giving? At present, the answer is a qualified "yes," but we are steadily gaining insights that are changing the answer to an unqualified "yes."
TABLE 1: Life expectancy, Health Inequality, and Ecological Footprint Health Life Ecological Inequality Expectancy Footprint (rank order) (rank order) (ha/cap) Sweden lowest 2 5.9 Spain 2 3 3.8 Netherlands 3 4 5.3 Switzerland 4 1 5 UK 5 5 5.2 USA highest 6 10.3 TABLE 2: Change in life expectancy, 1989-1999, successful societies (Cornia, 2000) Male Female Czech Republic +3.3 +2.7 Slovenia +2.6 +2.1 Slovakia +2.2 +1.8 Poland +2.1 +2.0 TABLE 3: Change in life expectancy, 1989-1999, in-betweeners (Cornia, 2000) Male Female Hungary +0.9 +1.3 Bulgaria -0.7 -0.3 Romania -0.4 +1.3 Latvia -0.4 +1.0 Estonia -0.3 +1.4 Lithuania +0.2 +1.4 TABLE 4: Change in life expectancy, 1989-1999, failed societies (Cornia, 2000) Male Female Belarus -4.6 -2.5 Russia -4.3 -2.1 Ukraine -3.0 -1.3 Kazakstan -3.6 -2.1 TABLE 5: Success versus failure, 1; 1989-1997 (UNICEF 1999) Czech Russia % of births to women < 20 -43% +32% Infant mortality -41% -3.5% < 5 mortality -36% -5% Mortality 20-39 women -13% +43% men -13% +45% Mortality 60+ -14% +15% TABLE 6: Success versus failure, 2; 1989-1997 (UNICEF 1999) Czech Russia Kindergarten enrollments -7.5% -19% Children in infant homes (per 000, 0-3) no +64% change Sentencing rate +4% +132% Change in GDP -3% -44.3% Real wages 2.3% -55.4% GINI (1989-1996/7) .20-.26 .27-.48 TABLE 7: Success versus failure, 3 (Cornia 2000) Czech Russia Privatization slow, fast, equitable inequitable Wage arrears very rare common Minimum wage/average wage 1995 26.9% 8.8% Migration rate (1989-94) 0.98% 5.5% TABLE 8: Institutional trust (mid 1990s) (New Democracy/New Russia Barometers) Czech Russia Political parties 15% 11% Courts 25% 20% Police 29% 16% Civil servants 27% 16% Military 31% 47% Parliament 15% 22% Churches 29% 29% Trade unions 28% 17% President 60% 25% Private 34% 16% Ratio: non-military trust / military trust 0.94 0.41
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Professor, Department of Health Care and Epidemiology
Faculty of Medicine, University of British Columbia…