Effect of democracy on health: ecological study

Abstract

Politics and health Since Virchow's seminal work, in which medicine was first proposed as a political science,2 politics has often been referred to in the medical literature, although mostly at a rhetorical level.3 Studies of political epidemiology are therefore needed, with research focusing on the effects on health of the institutions derived from political power. Some authors have tried to determine empirically whether governments can have an effect on the incidence of specific health problems. Studies in the United Kingdom and elsewhere have measured the effect of Labour and Conservative governments on suicide rates.4 More recently, welfare state policies have been associated with health benefits in people from countries belonging to the Organisation for Economic Cooperation and Development.5 Data are now available to enable the measurement of the global impact on health of a wide range of political and economic variables. As a result the World Health Organization commission on macroeconomics and health has produced valuable information on associations between health and wealth.6 Yet information is still lacking on the relation between the extent of freedom of a particular country and the health of its people. Each year, Freedom House, a non-profit making, independent organisation promoting democracy, publishes a freedom rating for most countries, classifying them as free, partially free, or not free.7 These ratings could be used as a proxy to explore the effects of democracy on health, as has been done recently with democracy and the provision of public services.8 Key informers of data for freedom ratings Political rights Elected rule Competitive parties or political groupings Opposition with actual power Self government of minority groups or their participation in the government Civil liberties Freedom of expression, assembly, association, education, and religion System of rule of law Free economic activity Equality of opportunity High income countries tend to have democratic governments; dictatorships and lack of civil liberties and political rights tend to be concentrated in low income countries. The level of inequality within a country may be an important determinant of health.9 10 The potential confounding effect of wealth and its distribution within a country should therefore be taken into account in research on the impact of democracy on health. Footnotes Adjusted models for effect of democracy in 170 countries are on bmj.com We thank Adrian Buzzaqui, Diana Gil, Tomás Pascual, Jaime Latour, and Miquel Porta for shaping the hypothesis, making it testable, and analysing the data. Funding The PhD programme of Public Health, University of Alicante, holds a grant from the Centro de Estudios Mario Benedetti. The Observatory of Public Policies and Health is a research consortium of the universities of Alicante, Antioquia, Porto-Alegre, and San Salvador, which holds grants from the Spanish Agency for International Cooperation and the Generalitat Valenciana. Contributors CA-D and MTR developed the hypothesis. All the authors analysed the data, interpreted the results, and drafted the manuscript. CA-D is guarantor. Competing interests None declared.