James McGuire Wealth, Health, and Democracy in East Asia and Latin America Cambridge, 2010, 406 p.

 

Reviewed by Sara Niedzwiecki

University of North Carolina, Chapel Hill

 

 

This book seeks to answer a central question for comparative politics: What are the causes of national development? Situated in the intersection between political science and public health, the author takes a “development-as-capabilities” perspective. He defines development as the capacity to avoid premature mortality. “To live the life one chooses, one has to be alive” (15). The main finding of the book is that both policy and politics matter for explaining the probability of early death. In terms of policy, the public provision and financing of government programs that provide free basic health care to uninsured people decreases the probability of infant mortality. On the politics side, more years of democracy (measured through polity IV) promote the existence of the aforementioned mortality-reducing social services. The research includes both large-N analysis of 105 developing countries in the year 1990 and case studies of eight middle-income societies in Latin America and East Asia, namely: Argentina, Brazil, Chile, Costa Rica, Indonesia, South Korea, Taiwan and Thailand.

 

James McGuire is a professor in the Department of Government at Wesleyan University. His previous work focused on Peronism and democracy in Argentina, and now specializes in comparative politics, democracy, and public health. This book challenges the “wealthier is healthier” proposition. This competing theory includes three dimensions: higher levels of GDP per capita will achieve lower levels of infant mortality, steeper rises of GDP per capita will achieve steeper declines of infant mortality (progress), and periods of high GDP per capita growth will achieve further reductions in infant mortality (tempo). Partly confirming the rival theory, the author finds that socioeconomic factors have a stronger effect on the levels but social provision is a better predictor of progress or change towards reducing infant mortality. The tempo of early death contradicts the “wealthier is healthier” theory. Periods of slow or negative GDP per capita growth coincided in some countries with sharp decline in infant mortality. In Argentina, Brazil, Chile and Thailand intervals of greater GDP per capita growth were, on average, periods of slower infant mortality decline. Accordingly, in a context of good performance on income-related indicators, Indonesia and Thailand slowed the pace of infant mortality.

 

The quantitative chapter is a cross-sectional analysis of all developing countries in the year 1990. McGuire finds that the utilization of basic social services statistically and significantly reduces infant mortality. Moreover, long-term democratic experience is associated with both increases in the provision of social services and with reductions in infant mortality. The following variables statistically and significantly reduce infant mortality thus confirming “the wealthier is healthier” hypothesis: higher GDP per capita, lower inequality, higher population density, higher urbanization, lower ethno-linguistic fractionalization, lower fertility and having a population that is less than 90 percent Muslim (to represent potential obstacles for finding resources for girls, 36).

 

Eight country studies throughout 40 years allow McGuire to unravel the causal mechanisms though which economic factors and the provision of basic social services determine the pace and extent of infant mortality decline from 1960 to 2005. These cases indicate two routes to the decline in infant mortality. The first of these is the growth-mediated security path followed by Taiwan and South Korea, which involves rapid GDP growth and decrease in income inequality, as well as effective provision of education, family planning and basic health care, together with the redistribution of land and the promotion of labor intensive manufacturing. The second of these two routes is the support-led security route followed by Chile and Costa Rica, which involves the provision of basic health care to mothers and children in a context of slow economic growth and relatively high inequality. Although the first route may be more desirable, the second one is often more feasible (22).

 

Bringing the quantitative and qualitative evidence together, McGuire concludes the book with his main argument: “Democracy (especially long democratic experience) generally did promote the public provision and expanded utilization of basic health care, education, family planning, water, and sanitation services, in more diverse ways than is often recognized. These social services, in turn, were associated with lower infant mortality, even after economic, demographic, geographic and cultural circumstances were taken into account” (278). Democracy enhances policies that expand human capabilities as well as it encourages discussions of the most basic needs. Democratic regimes achieve these goals through providing freedom of expression and association and through citizens’ expectations of social rights; all of which influence the different stages of policy making (296).

 

The “wealthier is healthier” thesis received partial support as an alternative path towards infant mortality reduction. Both regression analysis and process tracing showed that South Korea and Taiwan’s reduction in infant mortality is mostly explained by the seven socioeconomic variables included in the analysis. Brazil, Indonesia and, to a lesser extent Argentina, also seem to follow this path. Contrarily, Chile, Costa Rica and Thailand provide further support for the policy-oriented or support-led security route. In these cases, the government provided improved basic health services to the poor.

 

The main shortcomings of the book are the choice of a cross-sectional (and not time series cross-sectional) model and the measurement of democracy. The choice of a pure cross-sectional model around the year 1990 is problematic since the processes that the author is interested in explaining are inherently dynamic. In the four decades covered by the book, there are both changes within countries over time and changes between countries. The decision to only analyze cross-country changes around the year 1990 greatly diminishes the explanatory power of the research. By the same token, the choice of taking the mean values of the variables is also problematic. In particular, long-term democratic experience measured as a country’s mean polity from 1900 to 1990 is deficient since the mean throughout such a long trend could be reflecting very different democratic patterns. In other words, the assumption is that different democratic trajectories that end up with similar average values impact infant mortality equally. Given this measurement error, three regression results are surprising: democracy does not seem to be associated with health spending, democracy is associated with access to improved water but not to sanitation, and long-term democracy significantly accounts for a higher share of births attended by trained personnel but not more child immunization coverage. Finally, and as McGuire (32-33) discusses, using Polity IV as an indicator for long-term democracy allows for covering long time periods and countries, but is conceptually problematic. In particular, Polity IV rests on a minimalist conceptualization of democracy that neglects popular participation and civil liberties.

 

In spite of these critiques, this book is an excellent example of theoretically and politically relevant research, addressed to academics and policy makers alike. Theoretically, the book successfully shows the mechanisms through which democracy contributes to the implementation of mortality-reducing policies in particular contexts. Additionally, and against the “wealthier is healthier” thesis, good quality primary health care programs can reduce infant mortality even in the context of economic downturns. Politically, the main policy advice is the need to develop “effective public provision – free of charge to the user and regardless of insurance coverage – of inexpensive basic health services to people experiencing a high risk of early death” (309). These basic health care programs, which proved to significantly reduce infant mortality, are inexpensive. Therefore, these policies are attainable goals.