I previously discussed why life expectancy isn’t a good measure of the quality of a nation’s healthcare system. In spite of numerous economic indexes that focus on it, life expectancy is also a rather poor proxy for quality of life. There is a persistent narrative that Japan, Western Europe, and the Scandanavian countries, due to high per capita income, top of the charts lifespans, and asset ownership rates must be the “happiest” people in the world, with the highest quality of life. While it is understandable that people who create these indexes will be biased towards considerations that make their own countries or cultures look the best, these indexes are also used to defend or promote public policy decisions based on specific cultural norms. To those like me who are proponents of health-centered public policy, Quality of Life indices that ignore the daily health experience are more popularity contests than useful measures.
Specifically looking at indexes such as the Economist’s Where-to-be-born index, we can see that although there are compelling normative variables used – such as gender equality, political freedoms, and corruption – few of the variables directly address the actual experience of happiness. For example, focusing on high level statistics such as gender equality (which is defined very narrowly as the number of women who hold elected seats in legislature) it ignores the actual daily experiences of sexism that still occur even when women are nominally awarded seats at the table. Further, all of these indices exclude qualitative data directly from the citizens of the countries being measured. Given that national bodies like the federal government and supra-national bodies like the WHO and UN set spending priorities based on these metrics, not including data points generated from the people themselves misses a huge part of the picture of public health.
Some questions that are left unanswered by using only the Western normative criteria for measuring quality of life:
1) What is the marginal cost of keeping a citizen alive each year beyond retirement age?
2) What is the rate of drug or alcohol addiction?
3) What is the suicide rate?
4) What is the rate of death from preventable chronic disease?
5) What portion of the population believes they require medication for normal daily functioning?
6) What is the level of air and water pollution? What types of pollutants are present in food and water consumed?
7) How sustainable is the current level of energy consumption?
8) What is the prevalence of chronic mental health issues such as depression, anxiety, or schizophrenia?
9) What level of tolerance do people have for others who have different values or religion than themselves?
10) How much do citizens earn in income relative to the value they produce?
11) How much time do citizens spend at work vs with their family or friends? How much time would they prefer to spend with either?
12) How much time is spent on a computer or smartphone per day?
13) In what direction and speed are each of the above elements trending?
The questions above focus more closely on how citizens relate to the world around them – their economy, their medical system, their neighbors, and themselves. They offer a much more honest look at the true level of satisfaction the average citizen extracts from their daily life experience
The fundamental challenge here is the question who is better off?
A) Person A: Makes $80k/year, will live to 83, is chronically depressed, requires copious amounts of alcohol (or Facebook, or porn, choose your addiction) and painkillers to get through the day, overweight with arthritis in the knees, spends 10 hours per day in front of a computer or smartphone, lives in Sweden
B) Person B: Makes $30k/year, will live to 77, surfs everyday, drinks minimally, babysits their grandchildren several days per week, lives in Brazil
According to most normative measures, Person A is considered to be better off simply because the normative values of Sweden are preferred over that of Brazil. However, physically and mentally, Person B is clearly better off. From a policy perspective, Person B has the much better daily life experience, and such a daily life experience is clearly more economically sustainable in the long term than that of Person A – especially when you consider that birthrates in many of the countries at the top of indexes like the Where-to-be-born index are below replacement.
An additional point that should not be forgotten is how high levels of inequality can paint a picture that is rosier than reality if metrics focus on average results, rather than median or mode. For example, in the US, the prevalence of obesity for people in the bottom quintile of income is 15% higher than that of people in the highest quintile. This 15% difference translates into a difference of tens of millions of dollars worth of care consumed, a much higher rate of hospital utilization, and significantly worse overall health outcomes. For many communities within the US, patients would likely receive higher quality care and better health outcomes if they lived in Cuba. Likewise for a country rated poorly on the standard quality of life scales – if you are born to a rich family in Zimbabwe, your quality of life and health outcomes will resemble those of someone born in Sweden more than a fellow Zimbabwean born into a poor family.
Some alternative measures to the normative Quality of Life index include the the Happy Planet Index, which measures the average quality of life in a nation based on Experienced well being (qualitative polling), life expectancy, and ecological footprint. While again, life expectancy is not a desireable variable to use, at least the HPI heavily focuses its methodology on how citizens relate to the world around them, rather than on easily doctored normative metrics like unemployment (are we using U3, U5, or U6?), “political freedoms”, or corruption (is lobbying post-Citizen’s United not merely a legalized form of corruption?). More importantly, the New Economics Foundation – makers of HPI – acknowledge that from a policy perspective, HPI should be used in conjunction with other measures such as “economic performance and environmental pressure.”
Ultimately, it is important to move away from normative measures of quality of life that merely reinfornce our cultural biases. Doing so will allow us to take a critical look at the serious stresses that our current economic habits place on our overall mental and physical health. Pretending that a place is paradise or even merely possesses superior public policy/culture simply because life expectancy and incomes are higher than anywhere else is a very dangerous delusion.