How sustained economic growth influences health through nutrition and better living conditions
THE LAST WORD | ANDREW M. MWENDA | In this column last week I argued that economic growth, in spite of its many limitations, remains the most important driver of improved wellbeing. A key measure of wellbeing is increased life expectancy at birth. People who feed poorly and live in horrible conditions are prone to diseases and would, therefore, die young. Infant/child mortality has the biggest impact on life expectancy. For instance, life expectancy at birth in Uganda is about 65 years, compared to Japan at 84.5 years. But life expectancy at 15 years in Uganda could be nearer that of Japan. This shows that after overcoming the health challenges of early childhood, most people live longer.
There is a truly great book by Thomas McKoewn titled, The Role of Medicine: Dream, Mirage, or Nemesis? McKoewn is the founder of social medicine and argues that medicine is not very useful in improving health. In a series of famous diagrams, he demonstrates that for a whole range of diseases, mortality rates were falling long before the introduction of effective treatment, and (interestingly) continued to fall almost at the same rate after its introduction. A medical doctor himself, McKoewn argued that medicine is not very useful, even arguing that the more highly qualified a doctor is the more useless he or she was likely to be.
McKoewn argued that the roots of health improvement lay in economic and social progress particularly nutrition and better living conditions. Better-fed children have greater resistance to diseases than malnourished ones. The biggest, but certainly not the only, influence on both improved nutrition and improved living conditions is income. Of course education also plays an important part: better educated people are more likely to embrace modern living standards, eat a more balanced diet and know the germ theory of disease (like wash hands before they eat) than less educated ones. But without income some of these things are unaffordable – hence the centrality of economic growth to wellbeing.
This is why, recognising that his own professional efforts could do little to improve public health, McKoewn turned to more social ills such as poverty and deprivation, which he saw as fundamental causes of poor health. He felt that gradual improvement in the material conditions of life such as better food and better housing were much more important than either healthcare or public health measures. This goes against the official attitude of Uganda government health policy whose implicit assumption is that health is primarily determined by medical treatment hence our oversized investment in hospitals and doctors.
Last week, I gave statistics on the improvements in the quality of housing in Uganda, a good proxy for both improved incomes and education/exposure. When I walk through my village of Kanyandahi in Kabarole District, I meet many educated people living in better houses with better furniture than their neighbours who actually have higher incomes but are not educated. This has taught me that education/exposure are important, even more important, to improved wellbeing than income. However, I am acutely aware that even with a good education/exposure, one still needs better income to afford those things that improve the quality of living.
McKoewn overemphasised the role of nutrition and better living conditions to improved wellbeing. He ignored the importance of the control of disease through public health measures such as supply of clean water, improved sanitation and vector control to improved health. Indeed, the economist and historian, Richard Easterlin, has shown that there is divergence in the onset of economic growth and improvements in health. He demonstrates basing on studies of Northern Europe that the timing of both does not match.
Improved education (which brings awareness of the germ theory of disease leading to better personal and home hygiene) was critical to improved health. Also public health measures such as improved sanitation and water supplies are central to improved mortality. The other influences on mortality are vector control, immunisation and vaccination. These could never have come from the unaided role of economic growth. They came through political efforts by policy makers who may have felt political pressure to do so. But even then, the investments in these areas cannot be accomplished without increasing real incomes (economic growth), which makes it possible for government to fund them.
What is the takeaway from this story? It is that economic growth matters, but it does not automatically and wholly improve health and wellbeing. Political action is necessary; especially in such areas as sanitation, water supplies, sewerage treatment, vector control, immunisation and vaccination. Yet even here, states can only fund these programs (under political pressure) from public revenues whose increase is only possible through sustained economic growth.
For President Yoweri Museveni and his NRM government, the lesson is simple but fundamental. The ability of NWSC to take water across our towns (they were in 23 towns in 2013 and now they are in 256 towns) is a major success. The control of Malaria (its prevalence in Kampala is less than 1%, and across the country is under 15%) is great achievement. Contrary to the doomsday stories of many critics, the Ministry of Health of Uganda (it’s better to call it the “ministry of medical services”) has been very effective in containing outbreaks of epidemics such as cholera and dysentery in our congested city and Ebola in the rest of the country. However, more can be done; especially on sanitation.
Kampala and the surrounding Wakiso District are the most densely populated part of Uganda, making the transmission of water, air and food borne easy and rapid. Yet the city’s streets are filled with potholes holding muddy water and thus breeding grounds for mosquitoes and other bacteria-carrying diseases. City roads are congested with traffic, its sewers are open, its wetlands are encroached, its rivers are polluted, etc. This is a major failure; especially because Kampala and Wakiso are also the most productive part of our nation, contributing 75% of tax revenues.
The city’s economic opportunities are only rivaled by its health risks resulting from gross under investment in its infrastructure; especially its roads and green areas. Given our poverty (in spite of sustained growth), Uganda cannot afford many things our elites demand. However, it can afford a major investment in the city’s roads and green areas. In 2008, government made a bold decision to invest in national trunk roads and electricity generation. Twelve years later, the results are impressive. In 2020, government must make a similar bold decision to revamp Kampala. Is someone reading?