Lee on Riley, _Poverty and Life Expectancy: The Jamaica Paradox_

[eh.net-review at eh.net]

Published by EH.NET (February 2007)

James C. Riley, _Poverty and Life Expectancy: The Jamaica Paradox_. 
New York: Cambridge University Press, 2005. xiii + 235 pp. $60 
(hardback), ISBN: 0-521-85047-9.

Reviewed for EH.NET by Chulhee Lee, Department of Economics, Seoul 
National University.


How to improve the health of their people is a key policy issue for 
all nations, both rich and poor. For poor countries particularly, it 
is important to choose the right strategy to achieve the best 
possible outcome with limited resources. _Poverty and Life 
Expectancy: The Jamaica Paradox_ deals with this broader issue by 
focusing on the question of how some poor countries, such as Jamaica, 
managed to achieve high life expectancies. Riley argued recently, in 
_Rising Life Expectancy: A Global History_, that there are various 
paths toward achieving low morbidity and mortality. The case study of 
Jamaica is, perhaps, meant to highlight a particular historical path 
to a healthier society that demands relatively low costs.

Chapter 2 addresses questions about the timing and pace of mortality 
decline in Jamaica. According to official vital statistics, mortality 
at all ages began to decline in the 1920s, thanks largely to the 
decrease in deaths caused by communicable diseases, especially 
diarrhea, malaria, and tuberculosis. Jamaica's most rapid gains in 
life expectancy occurred in the period of 1925-1940. Gains from 1945 
to 1965 were nearly as rapid, but the pace slowed down thereafter. 
This chapter also touches on the issue of reliability of data 
sources, such as the registration of births and deaths and the 
results of periodic censuses, from which the statistical series of 
life expectancy and age-specific mortality were constructed. The 
author maintains that the estimated mortality could be understated 
because of the underreporting of deaths and emigrants, but the 
magnitude of potential bias should be moderate.

Chapters 3 through 6 attempt to offer explanations for the changes in 
life expectancy in each of the four periods, namely, prior to 1920, 
1920-1950, 1950-1972, and 1972-2000, by looking at the roles played 
by such factors as medicine, public health, the economy, the standard 
of living, the distribution of income, government activities, 
education, and personal hygiene. The first of these chapters examines 
Jamaica's situation on the eve of its mortality transition. By 1920, 
the British had built some basic medical and health infrastructure, 
such as a health care system led by district medical officers (DMOs) 
and hospitals. The number of schools and students increased over 
time, especially after school fees were discarded in 1892. However, 
the institutional and economic progress in that era failed to 
significantly improve life expectancy.

Chapter 4, the longest of the book, provides explanations for the 
rapid increase in life expectancy in Jamaica between 1920 and 1950, 
in which the expectation at birth rose from 35.9 years to 54.6 years. 
Riley suggests that the decline in mortality was not caused by an 
improvement in the standard of living, based on the facts that per 
capita GDP stagnated from 1910-1950, and that the dwelling conditions 
and nutritional status remained poor. Advancements in medicine and 
the establishment of expensive sanitary facilities, such as 
filtration and sewage systems, were not major contributors either. 
The author instead attributes the rapid rise in life expectancy to 
improvements in public health, education, and individual behavior. It 
is suggested that some low-cost public health measures, such as 
building sanitary latrines, safe disposal of human waste, interfering 
with housefly and mosquito breeding, and isolation of the sick, were 
effective in controlling the spread of diseases. Another key factor 
was the diffusion of knowledge through school education and public 
health campaigns that helped Jamaicans become better informed about 
the methods of disease prevention and avoidance.

Jamaica's health transition continued throughout the 1950s and 1960s, 
the period covered by Chapter 5, with life expectancy at birth rising 
from 54.6 years in 1950 to 69 years in 1972. Over these two decades, 
Jamaica's economy expanded more rapidly than ever. However, Riley 
maintains again that the increasing standard of living was not a 
major contributory factor to the improvement because the gains from 
economic growth were concentrated in small segments of the 
population, and the majority of Jamaicans continued to be troubled by 
unemployment and poverty. The author instead suggests that an 
increase in public sector spending on health, especially on the 
primary care system, was a more important force.

Chapter 6 examines how Jamaica managed to sustain, and even add to, 
its already high level of life expectancy in spite of its economic 
collapse and stagnation from 1973 to 2000. Hit by the first oil shock 
and troubled by outside influences and internal economic transitions, 
Jamaica experienced a prolonged period of negative economic growth, 
higher level of inflation, and higher unemployment. In spite of this 
economic debacle, death rates continued to decline in most age 
groups, though at a slower pace. Riley offers the following 
explanations for this puzzling phenomenon. First, the standard of 
living did not deteriorate as much as the statistics on income 
suggests, due to a more equitable distribution of income, a higher 
level of government spending on public services, earnings from the 
informal sector of the economy, and remittances from emigrants. 
Second, the government continued to strengthen public primary health 
care, focusing on democratic access to health care, counseling about 
infants and maternal health, and immunizations. In the concluding 
chapter, Riley suggests that "Jamaica's health transition was not a 
weak or second-best substitute in the programs and policies followed, 
but the robust demonstration of an alternative path" (p. 194).

This book is a useful introduction to the history of health 
transition in Jamaica over the twentieth century. It offers a vivid 
narrative about the pioneering efforts of organizations and 
individuals in the fight against diseases in a developing country. It 
also provides a clear picture of how living environments and sanitary 
conditions of ordinary Jamaican people changed over time. In spite of 
these merits, however, a few major points of the book did not fully 
convince me, and the reasons are described below.

First, the evidence given in the book is not rich enough to offer 
decisive conclusions. The main body of quantitative evidence, drawn 
from time-series statistics on a number of measures of health and 
economic conditions, is circumstantial, even if it is supplemented by 
various qualitative materials. Based on the given evidence, for 
example, it is difficult to accurately assess how many resources were 
actually devoted to particular activities pertaining to public 
health, medicine, and education, and how much of the decline in 
mortality was attributable to each factor.

Regarding the effectiveness of each of the potentially important 
factors of the health transition, in particular, more rigorous 
quantitative analyses would have made the case much stronger. For 
example, exploiting the fact that the timing of improvements in 
public health and medicine varied across parishes and that economic 
conditions substantially differed across regions and sectors, it 
would have been very fruitful to look at cross-sectional variations 
in the patterns of mortality decline.

In interpreting the given evidence, Riley would have benefited from 
considering the dynamic aspects of health changes over the life 
cycle. In light of recent findings that malnutrition and suffering 
infectious diseases in early life increase the risks of developing 
chronic illnesses at middle and old ages, it could be misleading to 
relate improvements in public health and standard of living in 
particular years only to the mortality decline that occurred during 
the same period. For example, the continued decline in mortality at 
an older age in the era of economic stagnation that began in 1973 
could be, in part, explained by the decline of infectious diseases 
and improvement in children's health which was achieved in earlier 
periods.

Second, I think that some special features of Jamaica as a colony of 
one of the world's most advanced country are not satisfactorily 
considered. As admitted in the book, the long-term improvement in 
health in Jamaica was jumpstarted by the British who planned and 
created its basic infrastructure, and by the Americans who sponsored 
early public health campaigns. Such transfers of up-to-date knowledge 
and institutions, as well as material resources, from richer 
countries could be responsible to some extent for the rapid health 
transition of Jamaica. It can thus be said that these inputs to 
Jamaica's health transition were the outcomes of the long-term 
economic and technological developments of advanced countries. 
Correspondingly, it would be unfair to conclude that an improvement 
in life expectancy can be obtained without economic growth based on 
Jamaica's experience.

My final point concerns the author's assertion that Jamaica's case 
demonstrates an alternative path of health transition. Since health 
is an important element of human well being, it is surely good to 
achieve a longer life expectancy, as Jamaica did. However, since 
health is not the only determinant of well being, it should be better 
to achieve a longer survivorship and economic growth at the same 
time, if possible. Indeed, a few countries, which were as poor and 
unhealthy as Jamaica in the early twentieth century, have become both 
healthier and more affluent than Jamaica today. Would it not 
therefore be wiser for today's poor countries to follow the paths of 
these countries rather than that of Jamaica?


Chulhee Lee is a Professor at the Department of Economics of Seoul 
National University. He is the author of "Wealth Accumulation and the 
Health of Union Army Veterans, 1860-1870," _Journal of Economic 
History_ 65 (June 2005), and "Labor Market Status of Older Males in 
Early-Twentieth-Century America," _Social Science History_ 29 (Spring 
2005), as well as numerous other articles on U.S. economic and 
demographic history.

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