Pakistani women jostle to receive their ballot papers prior to casting their ballot at a polling station on May 11, 2013 in

Lahore. A study in The Lancet provides evidence that free and fair elections are associated with a lower burden of chronic diseases. Daniel Berehulak/Getty Images hide caption

toggle caption Daniel Berehulak/Getty Images

Pakistani women jostle to receive their ballot papers prior to casting their ballot at a polling station on May 11, 2013 in Lahore. A study in The Lancet provides evidence that free and fair elections are associated with a lower burden of chronic diseases.

Daniel Berehulak/Getty Images

Here's a bit of heartening news to consider this Fourth of July: Democracy is good for our health.

A study published in The Lancet in April analyzed how the "democratic experience" of a country impacts the health of its citizens. The results were a clear win for democracy.

Democratic countries with free and fair elections generally had higher overall life expectancies among residents who were HIV-free than did autocracies. Democratic experience also eased the burden of chronic, noncommunicable diseases like heart disease or stroke, according to the study.

"This is a fascinating paper in that it tries to understand what affects health outcomes besides the income of a country," says Margaret Kruk, a professor of public health at Harvard who was not involved in the study.

Disentangling the effects of democracy from overall GDP is difficult, but Kruk says this paper represents a significant step forward in understanding how to address the shifting health needs of a developing world.

That democracy boosts public health might seem like common sense. People want better health care, and governments can help provide it. In a democracy, a government that fails to support health-care infrastructure can get voted out in favor of one that does. Autocratic governments that slack on health care face no such check.

Yet some of the most noticeable public health victories have occurred in the least democratic countries, according to Tom Bollyky, senior fellow for Global Health, Economics, and Development at the Council on Foreign Relations, who led the study and recently published a book expanding on the topic.

"China and Cuba were famously cited for producing good health for nations at low cost," says Bollyky. Life expectancy in Cuba is essentially identical to that of the U.S., in part due to a focus on primary care and prevention.

He also points to progress in other parts of the world where democracy is not flourishing: "Ethiopia, Rwanda, Uganda, Myanmar have all extended their life expectancy by 10 years or more since 1996, and were also big recipients of aid."

Bollyky explains that such rapid improvements were possible in part because there was a lot of low-hanging fruit for governments and aid programs to target. "The disease burden of these [less democratic] countries was characterized by the plagues and parasites that largely affect children," he says.

But things are changing.

Many low- and middle-income countries are at a turning point in their health care systems, says Kruk. She explains that relatively straightforward technological interventions, like anti-malarial bed nets, have largely worked. Now these countries are facing health problems that require a more stable and extensive infrastructure. Cardiovascular diseases, cancer, diabetes — "these require much broader and deeper investments in health systems, not just tools and technology," says Kruk.

To find out if democracies contribute to better outcomes in these kinds of diseases, Bollyky and his colleagues mined the Global Burden of Disease database and the Varieties of Democracy project, which capture yearly snapshots of the economic, political and medical health of 170 countries going back to 1980 through 2016.

"We wanted to look at adult life expectancy, and death rates from specific diseases and specific injuries, and see if there was a relationship with democracy," says Bollyky.

Democracy is a tricky thing to measure. Countries can vary in the components of democracy — suffrage, free and fair elections, freedom of the media — as well as how long those components have been in place. "Being a democracy for longer allows for some institutionalization of whatever positive effects it might have, so we wanted to capture that," says Bollyky. So the researchers calculated the "democratic experience" of each country, taking into account their cumulative "democratic stock."

To disentangle the effect of democracy from other variables, like gross domestic product or urban development, Bollyky employed a few different statistical techniques. "We can't just do a global experiment where we randomly [assign countries to be democratic] and see what happens," says Bollyky. "So we were really careful to isolate the effects of democracy."

Bollyky says that from these varied perspectives a clear pattern emerged — democracy is good for public health, especially for chronic diseases.

Controlling for other factors, adult life expectancy increased by 3% over 10 years for countries that transitioned to democracy during the period studied versus those that hadn't.

The study found that democratic experience played a larger role than GDP in reducing the burden of cardiovascular disease, traffic accidents, cancer and other noncommunicable diseases. Tuberculosis was also better managed under democracies, but most communicable diseases, like malaria or diarrhea, were generally not affected by democratic experience.

For every point increase in democratic experience, the researchers found a 2% reduction in deaths caused by these noncommunicable diseases. "That doesn't sound like a lot, but a lot of people die of cardiovascular disease globally," says Bollyky. "A 2% reduction over 20 years would mean an estimated 16 million deaths averted."

"In global health, anything where your intervention [democracy, in this case] beats GDP is a big deal," says Bollyky.

Why did democracy make a difference for these chronic conditions but not communicable diseases? In part, Bollyky says it's because non-communicable diseases are also among the least targeted diseases for international aid. In 2016 only 2% of international aid was spent on non-communicable diseases, which accounted for 58% of deaths and disability in low-income countries that year.

Without the benefit of international aid, the burden of caring for these conditions falls on individual countries.

Chronic conditions like heart disease tend to benefit from early identification by trained medical professionals, continual check-ups and a steady supply of safe and effective medication. A government that is responsive to voters is more likely to spend more money on health care for chronic conditions and invest in building durable health-care systems, according to Bollyky.

Less democratic countries don't have that electoral check. In fact, their analysis showed that free and fair elections were the most critical component of democratic experience. Without them, the significant difference democracy made for chronic conditions dissolved.

Kruk says this study shows that as the health needs of countries tip toward chronic conditions, what's worked in the past may not work in the future.

"I think this research provides one way forward," says Bollyky. "The challenge we're in now is that the health burden is shifting in low and middle income countries [from communicable to noncommunicable diseases], but international aid has stagnated, particularly for noncommunicable diseases that are rising fastest."

Bollyky suggests that aid organizations could adapt to these changing circumstances by adding democracy promotion to their portfolios, though he recognizes the political pitfalls inherent in that approach. "We need to depoliticize democracy promotion," says Bollyky. "Right now, most states that are becoming more autocratic aren't doing so through military coups, they're doing so through rigging elections."

Kruk is less convinced by this argument. "Their work suggests some interesting associations between democracy and important health outcomes, though I'd like to see it replicated," she says. "But I think it's a leap to say that therefore we should spend money on democracy promotion. I just don't know that there's a lot of evidence to support that those sorts of interventions work."

And of course, democratic experience does not ensure better outcomes. Other aspects of health policy, like access to insurance or adoption of technology, influence the health of a country.

Regardless of policy implications, Bollyky says "it's nice on the Fourth of July to have a bit of good news about democracy. When we look at the world around us there are lots of reasons to be discouraged, this study provides a bright spot."

Jonathan Lambert is a freelance science journalist based in Washington, D.C. You can follow him on Twitter: @evolambert


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