A recent paper by Franco et al. (2007) claims that increased poverty may improve health (see also NPR’s Marketplace report). How is this possible? Lower income reduces excess food as well as cigarette consumption. Further, poverty makes public transportation less affordable and individuals may substitute walking for taking the bus. The authors study Cuba’s experience between 1989 and 2005.
Cuba has been subjected to an economic embargo by the United States since the 1960s. After the loss of the Soviet Union as a trading partner in 1989, Cuba entered a prolonged economic crisis known as the ‘‘Special Period.’’ The crisis worsened continuously over the next 5 years, with economic output reaching a nadir in 1995 of about half the level in 1990.
The decreased economic activity lead to the following changes:
- Calorie intake: “Average per capita daily energy intake…declined from 2,899 kcal in 1988 to 1,863 kcal in 1993.”
- Physical Activity: “In 1987, only 30 percent of the population living in Havana was characterized as physically active. In national data, approximately 70 percent of Cubans were considered physically active in 1991–1995, and 67 percent were active in 2001”
- Obesity: The prevalences of obesity in Havana were 11.9 percent, 5.4 percent, and 9.3 percent in 1982, 1994, and 1998, respectively. In Cienfuegos, prevalences were 14.3 percent, 7.2 percent, and 12.1 percent in 1990, 1995, and 2001, respectively, reflecting a 49 percent fall during the economic crisis.”
- Cigarette smoking: Cigarette smoking decreased over this period as well.
We see that the prevalence of many of risk factors declined during the “Special Period.” What were the affects on health?
- “In subsequent years (1997–2002), rates of mortality from type 2 diabetes, coronary heart disease, and all causes dropped 51 percent, 35 percent, and 18 percent, respectively…No significant changes in total cancer mortality were observed, consistent with the current knowledge that obesity is not strongly associated with this condition.”
So poverty is the answer? It turns out that all the news is not rosy:
- All-cause mortality among persons over the age of 65 years increased 13 percent from 1989 to 1996, primarily because of excess deaths from infections (21). The secular decline in infant mortality was interrupted for 3 years, and the incidence of low birth weight increased from 7.3 percent to 9.0 percent between 1989 and 1993 (21). An epidemic of optical and peripheral neuropathy attributed in part to vitamin and protein deficiencies affected 50,000 people between 1992 and 1993.”
Can these results be extended to other countries? Cuba is a communist country where health is provided publicly. The government can incur debt in order to provide medical care for its citizens. In the U.S., increased poverty will likely make medical care less affordable–for those not on Medicaid–and thus health outcomes may suffer. Further, long run economic decline will make the provision of even government-run high quality medical care unaffordable for a society. A final critique is that although the data presented in the paper is suggestive, correlation does not imply causation. One should always maintain a healthy skepticism regarding the conclusion of time-series correlation studies.While no economist would advocate for policy-makers to attempt to increase poverty, the Franco study may guide individuals into believing that “less is more,” at least when it comes to food intake and car usage.
- Franco M, Orduñez P, Caballero B, Tapia Granados JA, Lazo M, Bernal JL, Guallar E, Cooper RS (2007) “Impact of Energy Intake, Physical Activity, and Population-wide Weight Loss on Cardiovascular Disease and Diabetes Mortality in Cuba, 1980–2005” American Journal of Epidemiology, doi:10.1093/aje/kwm226.