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.