↳ Healthcare

March 9th, 2020

↳ Healthcare

Flanked by Two Dolphins


An ecosocial theory of disease

The correlation between health, income, and wealth is widely recognized in contemporary research and policy circles. This broadly social understanding of public health outcomes has its origins in a theoretical tradition dating back to the 1970s and 80s, in which scholars began to embed medical research within a political and economic framework.

In a 2001 paper, epidemiologist NANCY KRIEGER seeks to strengthen the theoretical foundations of epidemiological research by linking them back to biological study.

From the paper:

"If social epidemiologists are to gain clarity on causes of and barriers to reducing social inequalities in health, adequate theory is a necessity. Grappling with notions of causation raises issues of accountability and agency: simply invoking abstract notions like 'society' and disembodied 'genes' will not suffice. Instead, the central question becomes who and what is responsible for population patterns of health, disease, and well-being, as manifested in present, past and changing social inequalities in health?

Arising in part as a critique of proliferating theories that emphasize individuals' responsibility to choose healthy lifestyles, the political economy of health school explicitly addresses economic and political determinants of health and disease, including structural barriers to people living healthy lives. Yet, despite its invaluable contributions to identifying social determinants of population health, a political economy of health perspective affords few principles for investigating what these determinants are determining. I propose a theory that conceptualizes changing population patterns of health, disease and well-being in relation to each level of biological, ecological and social organization (e.g. cell, organ, organism/ individual, family, community, population, society, ecosystem). Unlike prior causal frameworks—whether of a triangle connecting 'host', 'agent' and 'environment', or a 'chain of causes' arrayed along a scale of biological organization, from 'society' to 'molecular and submolecular particles'—this framework is multidimensional and dynamic and allows us to elucidate population patterns of health, disease and well-being as biological expressions of social relations—potentially generating new knowledge and new grounds for action."

Link to the piece.

  • Krieger's 1994 article takes a closer look at epidemiological causal frameworks, questioning the adequacy of multiple causation. And her 2012 paper asks: "Who or what is a population?" and articulates the analytical significance of this definition for epidemiological research. Link and link.
  • "Disease epidemics are as much markers of modern civilization as they are threats to it." In NLR, Rob and Rodrick Wallace consider how the development of the global economy has altered the spread of epidemics, taking the 2014 Ebola outbreak as a case study. Link.
  • Samuel S. Myers and Jonathan A. Patz argue that climate change constitutes the "greatest public health challenge humanity has faced." Link.
  • A history of epidemics in the Roman Empire, from 27 BC – 476 AD, by Francois Relief and Louise Cilliers. Link. And a 1987 book by Ann Bowman Jannetta analyzes the impact of disease on institutional development in early modern Japan. Link.
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February 18th, 2020

The Importance of Being Evergreen


A comparative overview of national healthcare systems

In an employer-sponsored healthcare system like that of the United States, deteriorating labor market protections have immediate consequences for access to healthcare. Democratic primary candidates have presented a number of proposals to address declining rates of insurance, ranging in degrees of accessibility, coverage, and number of providers.

In her 1992 book, Healthcare Politics, ELLEN M. IMMERGUT seeks to explain America's healthcare system through a comparison of its history to Switzerland's, France's, and Sweden's. From the author's preface:

"I compare the politics of three countries where national health insurance had been proposed, but where, as a result of political struggles, the final policy results are diverse. Medical associations in all three countries had opposed national health insurance on the grounds that doctors preferred to work as private practitioners and not as government employees. How then could one explain the fact that Switzerland rejected national health insurance, France accepted it, and Sweden not only enacted national health insurance, but later converted its health system to a de facto national health service? The history of each case pointed insistently to the role played by standard political institutions. The Swiss referendum, the French parliament, and the Swedish executive bureaucracy emerged as key elements in an explanation of national health insurance politics in those countries.

The resulting book argues for the primacy of these institutions in explaining policy outcomes precisely because they facilitate or impede the entry of different groups into the policy-making process. In Switzerland, the public interest on any specific policy issue is viewed as the sum of the demands of individual citizens as expressed in national referenda. In Sweden, on the other hand, proper representation for policy issues is a matter of consensual agreements between interest groups, whose large memberships and democratic procedures ensure their responsiveness to the public. In France, the rules of representation stress the importance of an impartial executive standing above the particularistic claims of interest groups. But there is no linear relationship between a specific set of political institutions and the interest groups that will succeed or the health system that results. These histories are filled with unexpected events, sudden about faces, and new strategies. This book is a call to look at these histories, not just at the broad sweep of major events, but also at the seemingly minor struggles that make up daily political life. These are the battles that establish the constraints on politics, but they are also the junctures that extend the limits of the possible."

Link to a downloadable copy of the book.

  • "The postwar growth of public expenditures in the health sector and the growth of universalism in coverage of benefits is tied to the strength of the labor movement in each country." Vincent Navarro's influential 1989 paper situates healthcare policies within a broader distributional framework. Link.
  • "The idea of a British hospital system funded by its users is one which emerged only late in the 19th century. Before this, care was provided through thousands of voluntary hospitals." Martin Gorsky, John Mohan, and Tim Willis on "Mutualism and Healthcare" in the UK. And in a similar vein, David T. Beito's 2000 book on the fraternal societies which provided healthcare to millions of Americans throughout the 19th and early 20th centuries. Link and link.
  • A recent paper by Stefan Bauernschuster, Anastasia Driva, and Erik Hornung uses "the introduction of compulsory health insurance in the German Empire in 1884 as a natural experiment to study the impact of social health insurance on mortality," finding that "Bismarck’s health insurance generated a significant mortality reduction." Link.
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January 27th, 2020



Re-thinking industrial policy

Deindustrialization is a global phenomenon taking place more rapidly in middle- income countries than in high-income ones. Despite the global decline of manufacturing employment, "industrial policy" is increasingly salient in research and policy debates. But deindustrialization poses significant challenges for industrial strategy—particularly as it relates to direct state investment in productive capacity.

In a new article, "Industrial Policy in the 21st Century," Ha-Joon Chang and Antonio Andreoni lay the groundwork for a new theory of industrial policy:

"Since the 18th century, the debate surrounding industrial policy has been one of the most important in the political economy of development. We discuss a number of issues which cannot be accommodated within the neoclassical framework and which are also often neglected by evolutionary and structuralist contributions—namely, commitment under uncertainty, learning in production, macroeconomic management, and conflict management. We also address three new challenges for industrial policy makers in a changing world: the global value chain, the increasing financialization of the world economy, and changes in the rules of the global economic system.

Despite differences across countries in terms of their stages and levels of industrialization, their macroeconomic regimes and their political economy settings, the three sets of neglected issues we focus on are and will remain of paramount importance. The need to address long-term grand challenges like climate change calls for massive and coordinated investments in energy systems, production practices and mobility. The achievement of these global transformations still depends on micro-level structural changes in productive organizations and government interventions in creating new worlds of production as well as managing industrial and social restructuring."

Link to the piece.

  • "Industrial policy can no longer be about industry or manufacturing per se. As the world economy turns increasingly towards services, it is clear that we will need a conception of industrial policy that addresses the need to nurture and develop modern economic activities more broadly, including but not limited to manufacturing." Karl Aiginger and Dani Rodrik's introduction to the special issue of Industry, Competition, and Trade. Link. In the same issue, Nathan Lane presents a "New Empirics of Industrial Policy." Link.
  • In Industrial and Corporate Change, Mario Pianta, Matteo Lucchese, and Leopoldo Nascia assess the post-crisis industrial policies of the European Union and examine the potential for more active public investment policies in the years to come. Link.
  • John Waterbury's extensive comparison between the industrial strategies of Nasser and Sadat. Link. From 1993, Hajoon Chang on the importance of state intervention in the "political economy of industrial policy in South Korea." Link.
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