life and death in china: a reply

World Development, Vol. 20, No. 9, pp. 1305-1312, 1992. 030>750)3/92 $5.00 + 0.00

Printed in Great Britain. Pergamon Press Ltd

Life and Death in China: A Reply

AMARTYA SEN* Harvard University, Cambridge, Massachusetts

1. INTRODUCTION

There are two main problems with Peter Nolan and John Sender’s (1992) “critique”: (a) use of highly selective evidence to support their views, and (b) thoroughly distorted presentation of my views before proceeding to dispute them. The former is certainly worth discussing and their arguments are not without intellectual interest (even though I find their reasoning quite uncon- vincing), but the latter is quite tiresome and exasperating and should have less room in academic debates. I will try to correct the misrepresentations before discussing each of the substantive issues.

2. ECONOMIC GROWTH: TWO CHEERS, NOT THREE, NOR NONE

The general thematic background that Nolan and Sender (1992) have chosen for their discussion of Chinese growth and mortality is that my writings are thoroughly anti-growth. Allegedly, I have “emphasized the ineffectiveness of economic growth in achieving fundamentally important ends, especially the freedom to survive” (Section l).’ As proof of this they cite a part of a sentence where I am quoted as saying: “. . . it is quite possible for the freedom to live long to go down, while the level of economic opulence goes up” (Nolan and Sender, 1992, Section 1).

That assertion points to the possibility that economic growth and longevity might, in some circumstances, move in opposite directions, but can scarcely be seen as a general statement on “the ineffectiveness of economic growth.” In fact, what I had said in the complete sentence, of which Nolan and Sender chose to quote only one part, was the following;

The point to note here is that the positive freedom to lead a long life may well be typically enhanced by expansion of material prosperity, but the relation- ship is far from a tight one, and indeed it is quite possible for the freedom to live long to go down, while the level of economic opulence goes up (Sen, 1989, pp. 772-773).

This qualified applause for economic growth is converted by Nolan and Sender into a thesis of “the ineffectiveness of economic growth,” through amputating more than half of it. Falstaff had observed that “honour hath no skill in surgery”; Nolan and Sender show instead that distortion can thrive on skilled surgery.

Nor is it easy to see that my views “encourage the growing number of commentators on development who irresponsibly suggest that a rapid rate of growth of agricultural output makes little difference to the survival prospects of the rural poor” (Nolan and Sender 1992, Section 1). As the only example of such terrible “irresponsibil- ity,” Nolan and Sender quote from a paper of Jean Dreze (1988), which is not about the role of economic growth in general, but exclusively concerned with the experiences of famine prevention in Africa. Nolan and Sender (note 3) quote Drkze’s statement: “Rapid growth of the economy of Botswana, or of the agricultural sector in Kenya, or of food production in Zimbabwe explain at best only a small part of their success in averting famines” (Drkze, 1988, p. 56).

Aside from misidentifying the context of Dreze’s statement, Nolan and Sender’s skill in surgery is in operation here too. In the same paragraph, from which they quote selectively, Dreze also said that “the potential contribution of greater prosperity, if it involves vulnerable groups, cannot be denied.” The paragraph fol- lows a set of detailed case studies of successful famine prevention in sub-Saharan Africa, and Drkze observed in these concluding comments that the real achievements of various forms of economic growth in the countries in question had not entirely eliminated the threat of famine, and that in each of the countries public intervention had played a crucial role in enabling the poorer sections of the population to feed themselves in

*For helpful comments and suggestions. I am most grateful to Carl Riskin, and also to Jean Drize and Christopher Murray. Accepted: April 27, 1992.

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times of crisis (arising, for example, from droughts and the resulting disruptions of the rural economy). In an impressive display of deluding skill, Nolan and Sender convert this balanced assessment into an “an example” of the extremist approach that assumes that “a rapid rate of growth of agricultural output makes little difference to the survival prospects of the rural poor” (Nolan and Sender’s wording, Section 1).

Neither Jean Dreze nor I have ever suggested that economic growth is in general ineffective in raising well-being or reducing mortality. In fact, in our joint book (Dreze and Sen, 1989), we have extensively discussed the importance of economic growth and have illustrated this with the experiences of many Third World countries in achieving what we called “growth-mediated security.” Indeed, of the identified 10 top- performers in mortality reduction among the Third World countries, five (Hong Kong, Singa- pore, South Korea, Kuwait, United Arab Emi- rates) were put in the category of “growth- mediated security” (Dreze and Sen, 1989, chap- ter 10). We examined how, in these cases, economic growth had played exactly the role of reducing mortality astonishingly fast. Moreover, there were other countries doing well by economic growth without being quite so dramatically successful.

But we also discussed cases in which there had been fast growth of real income but very moder- ate success in mortality reduction (e.g., Brazil, Oman), and other cases in which real income had risen quite slowly but mortality rates had come down remarkably fast (e.g., prereform China, Costa Rica. Jamaica). We analyzed why and how economic growth is much more successful in some cases than in others, in reducing mortality and expanding longevity (Dreze and Sen, 1989, chapters l&12). It is amazing that Nolan and Sender (1992) would convert all this into the odd thesis of a general “ineffectiveness of economic growth.”

3. DEATH RATES: CHINESE OFFICIAL FIGURES

Nolan and Sender’s distortions are not con- fined only to views on economic growth, but extend to their representation of my reading of Chinese experience and my allegedly “emphatic” acceptance of Chinese official statistics. They quote me as saying: “The official figures . record an increase in the general mortality rates after the reforms, with a considerably higher death rate than what China had achieved by 1979.” This is fine, but they preface that quota-

tion by the thoroughly misleading statement that Sen “is emphatic in his interpretation of the statistics concerning death rates in China” (Nolan and Sender, 1992, Section 1). Taking that to be a decisive pointer to my views on Chinese death rates, they move on to the next topic (viz. life expectancy).

There are two issues here. First, do the Chinese official statistics indicate such a rise in death rate in China compared with “what China had achieved by 1979”? Second, what was my reading of the reliability and significance of these figures? In fact. I had expressed great skepticism of these figures of death rates, which Nolan and Sender choose to ignore. (They do not themselves much discuss issues of reliability and significance of these figures from Statistical Yeur- books, perhaps because they rely so much on those Yearbooks to do the rest of their analysis.) There are problems regarding the reliability and coverage of these official death rates and also difficulties in interpreting them (due to such factors as changing age composition), and I shall come to these difficult issues in the next section. In this section, I deal specifically with the simpler question regarding what the Chinese official death rates are, and in that context, also discuss the counterclaims that are made by Nolan and Sender.

Nolan and Sender deny that the Chinese official statistics show what I claimed they did. Indeed, they argue that ‘the official data show no trend increase in death rates for China as a whole during the reform period” (Section 3a). I believe that this issue is easily settled by comparing the time series of death rates in the Chinese Statistid Yearbooks. The reporting on different years have varied a little from Yearbook to Yearbook, but they all do indeed show that the death rates were consistently higher following the economic reforms of 1979. To minimize any argument about which source to use, I am happy to take Nolan and Sender’s own Table 15, drawn from the Chinese Stutisticul Yearbook 1990. I reproduce below the numbers for 1978-79, and the figures after the reforms of 1979, from 1980 to 1989.

It is hard not to conclude from this that the Chinese official figures do “record an increase in the general mortality rates after the reforms, with a considerably higher death rate than what China had achieved by 1979.”

At the time I wrote those words, the figures for the late 1980s were, of course. not there, and my focus was mainly on the increase in the death rates in the early period after the reforms. By 1983 the all-China death rate was up by nearly one per thousand (15% above the 1979 level) and the rural death rate by considerably more (20%

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Table 1. China’s death rates (number per 1,000)

All China Rural

Number per Index Number per Index thousand 1979 base thousand 1979 base

1978 1979

6.3 6.2

1980 6.3 1981 6.4 1982 6.6 1983 7.1 1984 6.7 1985 6.6 1986 6.7 1987 6.7 1988 6.6 1989 6.5

102 6.4 100 6.4

102 103 106 115 108 106 108 108 106 105

6.5 6.5 7.0 7.7 6.7 6.7 6.7

6.7

100 100

102 102 109 120 105 105 105

-

105

Sources: State Sta/istical Bureau (1990), and Nolan and Sender (1992), Table 15.

above the 1979 level). But even the later figures, which do show a decline compared with the early post-reform years, indicate a higher death rate in China as a whole (and in rural China) than “what China had achieved by 1979.” The official figure for death rate for every year in the 1980s remained higher than the low figures achieved by China preceding the reforms.

It is baffling that Nolan and Sender should believe, with the full knowledge of these figures, that “the official data show no trend increase in death rates for China as a whole during the reform period” (Section 3a), or that “contrary to the propositions made by Sen, post-Mao China saw a geographically widespread decline in death rates, compared to the late Mao years, and little change from the exceptionally low figures achieved in the late 1970s” (Section 4). I can only presume that they do not take full note of the decline in death rates during the 1970s in the pre- reform period, and choose as their comparison point not what was achieved by the time of the reforms of 1979, but some kind of an average for the 1970s as a whole. If so, this would make little sense in the context of examining the contrast between the achievements made by the time of the economic reforms of 1979 and those ushered in by the reforms.

Alternatively, perhaps Nolan and Sender are proposing a modification of the question I asked about the effects of the economic reforms of 1979, rather than giving a different answer to it. Indeed, elsewhere in their paper, while discus-

sing production and market institutions, they suggest a reperiodization of Chinese history. They claim that “in order to analyze the effect of post-Mao policies on economic performance the most appropriate base period is the late Mao years, 1973-75 (excluding the politically turbu- lent year of 1976), rather than the late 1970s” (Section 2a). In this context they refer to “Deng Xiaoping’s rise to power” as a watershed. They mention no date for this event, but this reference occurs just after their statement that “the ‘Gang of Four’ was arrested in October 1976” (Section 2a). In fact, Deng was formally returned to his official positions in 1977, but did not consolidate his power until the Third Plenum of the Eleventh Central Committee in December 1978. Hua Guofeng, Mao’s chosen successor, not men- tioned by Nolan and Sender, had the main leadership role in China in much of the second half of the 1970s. The economic reforms of 1979 fit well into the change following Deng’s victory in December 1978.2 So the watershed of Deng’s

rise to effective power takes us exactly to the contrast I have actually examined.

Finally, if one is concerned about year-to-year fluctuations, it is possible to check the move- ments of two-year or three-year moving aver- ages. It is easily checked that this too confirms a rise following the economic reforms of 1979. For example, the three-year moving average for the total death rate bottoms out at 6.27 during 1978- 80, then rises to 6.80 by 1982-84 and 1983-85, followed by a smaller fall to 6.60 by 1987-89, but


remains well above the 1978-80 average. The story that the official figures tell is exactly what I had claimed they did.

4. DEATH RATES: INFORMATION AND UNCERTAINTIES

But how reliable and significant are these official figures of death rates? I believe they are very doubtful indeed, and had said so, even though Nolan and Sender chose to ignore all those remarks (in line with their account of my allegedly “emphatic” interpretation of these Chi- nese statistics, Section 1). What I had, in fact, said - following the part quoted by Nolan and Sender - was: “There are problems in interpreting the available data and difficulties in arriving at firm conclusions” (Sen, 1990, p. 65). Else- where, I had said: “Questions can be raised about the acceptability of these official mortality statistics” (Sen, 1989, p. 776). Nolan and Sender suppress these statements.

In our joint book, Jean Dreze and 1 had repeated these qualifications:

There is much room for doubt about the correctness of the official Chinese mortality data. It must be particularly noted that an increase in the coverage of mortality statistics may have the effect of raising the reported death rate. It is quite possible that at least some part of the apparent increase in mortality rates after 1979 is connected with better coverage of death data. Also we have to take note of the changing age composition of the Chinese population when interpreting overall death rates (DrPze and Sen, 1989. p. 216).

Jean Dreze and I had presented and scrutinized data from various sources on Chinese mortality rates and had drawn some qualified conclusions (Dreze and Sen, 1989, pp. 215-221).’ Compared with the rapid decline in the death rate in the pre- reform period, there was certainly evidence of some slackening of pace in mortality reduction in China, and on the basis of the data then available, we could not rule out the possibility that the decline may well have been “reversed” in the short period. The issue, however, is not so much whether age-specific mortality rates actually declined (they typically have a falling trend in most countries in the world on a fairly steady basis because of standard improvements in medical knowledge and use), but the rates at which they fall. In the Chinese case. the interesting comparison is with the rapid fall in mortality rates in the pre-reform period.

The analyses presented in Dreze and Sen (1989) and in Sen (1989. 1990) made use of the

demographic information and studies that were available at the time (Sen, 1989 was a lecture given in Washington, DC. in 1987 and Sen, 1990 another lecture given at the American Academy in 1989). More information has become recently available, primarily from demographic analyses of population surveys.4 Some unpublished, pre- liminary results presented by Ansley Coale and Judith Banister in seminars at the Harvard Center for Population and Development Studies indicate that the mortality picture may, in fact, be considerably more favorable than the official death rates suggest.5 This is fully consistent with my cautionary statements about the official death rates.

The analysis of the new survey data, however, are hard to use for a comparative picture between the 1980s and the situation in the late 1970s preceding the reforms, since there are no similar surveys available for that period. Nevertheless, we will certainly learn more about the post- reform situation when the analyses of these later data are completed, scrutinized and published. While it is important to keep an open mind on this question, it is not unreasonable to hope that the decline in mortality rates has continued through the 198Os, and ‘that the picture is considerably more satisfactory than it looks from the official death rates. But it would be extraordi- narily surprising if the achievements of economic reforms in dramatically raising the growth of income and output per head would be shown to be matched by a similarly improved performance in reducing mortality rates (including those of children), which were falling very sharply in the pre-reform period. I see no reason yet to revise my general conclusion that while income and output went up unambiguously and sharply after the economic reforms, “judged in terms of the freedom to avoid escapable mortality. the picture is much muddier” (Sen, 1989, p. 776).

5. LIFE EXPECTANCY

Given the uncertainties about the mortality rates, it is not surprising that there is a similar “muddiness” about life expectancy statistics. While I have not been able to locate the exact statement on Chinese life expectancy that Nolan and Sender (Section I) attribute to me (citing Sen, 1989. p. 774, where there is no such statement), I did make the following statement in the same paper: “Even in Figure 1, one notices a slight tendency for the life expectancy to decline in the period following the economic reforms” (Sen, 1989, p. 776). Figure 1 was reproduced

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from an earlier paper (Sen, 1987), and there the estimates for Chinese life expectancy at birth were, in turn, taken from a paper of Judith Banister (1984). Obviously the data could not have gone much into the 1980s (as the diagram made clear), and what I said in the statement quoted above is exactly what Banister’s estimates indicated.

Subsequently, Banister extended these calcula- tions (Banister, 1987, Table 4.12). In Dreze and Sen (1989, Tabie 11.3), we quoted her time series of estimated life expectancy. For males this rose a little from 64.3 years in 1979 to 64.9 in 1984, whereas for females it fell quite sharply from 65.7 in 1979 to 64.1 in 1984, with an overall decline for males and females put together (from 65.0 to 64.6).

While quoting these figures, however, we did make cautionary qualifications (partly based on my conversations with Ansley Coale and Judith Banister herself), and we felt that we could not go beyond claiming the following:

These estimates are speculative and must not be taken too seriously, but altogether there is much evidence of (1) a slow down or a halt in the steadily improving survival chances of both men and women, and specifically children, and (2) on top of that, an evident increase in gender bias, specifically affecting female children (D&e and Sen, 1989, p. 218).

Nolan and Sender want none of these uncertainties about life expectancy, and present (in their Table 20) some summary information from World Development Reports of the World Bank which assert that life expectancy at birth went up sharply from 64 years in 1979 to 69 years in 1984 (the same period over which Banister, 1987 had estimated a decline from 65.0 to 64.6). They proceed to conclude that “there was no decline, but rather a large increase in average life expectancy in the 1980s” (Nolan and Sender, 1992, Section 3b).

We are, in fact, told so little about the exact way in which life expectancy figures are calcu- lated for the World Development Report that it would be hard to take this as settling a complex academic discussion. There are also interesting year-to-year jumps in these World Bank estimates. For example, if instead of looking at the World Development Report 1981 (and finding a figure of 64 years for 1979), Nolan and Sender had looked at the World Development Report 1980, they would have seen a life expectancy of 70 years for 1978! I would not take that as evidence that life expectancy collapsed drasti- cally from 70 years to 64 years in one year (between the pre-reform 1978 and the year of

reforms 1979), which would be a tale of great absurdity, but nor would I accept the contrary picture of “a large increase in average life expectancy” on the basis of another figure from another World Development Report, selected by Nolan and Sender.

The picture remains “muddy.” It might quite possibly turn out that there has been a significant increase in life expectancy in China during the 1980s (and that overall development would not be inconsistent with the problematic early 198Os), but the proof of that cannot rest on what Nolan and Sender have given us. In particular, the World Bank account of the upward jump of life expectancy from 64 to 69 years between 1979 and 1984 is not adequate to settle any dispute, even though we should not, on the other side, buy the other World Bank story that life expectancy fell from 70 to 64 years between 1978 and 1979, or the alternative story told by the Chinese Statistical Yearbooks that the death rates rose from 6.2 per thousand to 6.7 between 1979 and 1984.

6. RURAL HEALTH CARE

The delivery of health care was the central concern in my worry about post-reform China’s ability to build on what had already been achieved in the pre-reform period (Sen, 1989, pp. 776777). It was not just a question of the decline in the number of barefoot doctors, but a general problem of financing rural health care and health insurance in a new regime of privatized agriculture. The rationale of Chinese health delivery in the years of its rapid achievement in the pre- reform period had been low-cost medicine being provided on a widespread basis on communal accounts. With the privatization of agriculture the availability of communal funds for health care became more problematic, and the coverage of rural health insurance went rapidly down - from 89% in the late 1970s to 10% by 1987 (as Nolan and Sender themselves state in Section 2c, citing Davis, 1989).

As against that Nolan and Sender present various qualifications to this picture. Some of these have considerable merit, while others are based on somewhat misleading statistics.h They end the section with pointing to the actual increase that has taken place in the general availability of health provisions per head, such as hospital beds and health personnel (Tables 8- 11). These are certainly relevant factors in making an overall judgment, but there is still a distinction between “availability” and “entitlement” much like the one that turns out to be

central to understanding famines and hunger.’ consequences of the reform policies” (p. 279). With privatization and economic prosperity, the but I shall not pursue this line of investigation demand for health services certainly does tend to further here. It is sufficient to note that there is a increase on the part of those who can afford to real problem here that needs to be addressed, pay, and the quality of health care for those who and that cannot be dismissed by simply referring can pay for it may also improve. The issue that is to the high overall economic growth of China in bothersome is the inability of the uninsured rural the post-reform period, or even to the growth of poor to afford health care. average availability of medical resources in rural

The advantage of cooperative medical services China. and communal insurance is their ability to cover more vulnerable people, guaranteeing entitlement to some basic health care and medical 7. CONCLUDING REMARKS attention. This can affect mortality rates too. For example, Knight and Song (1991) estimate on the I have tried to correct some of the distortions basis of a 1987 survey of “52 villages, containing of my position that are to be found in Nolan and 62,000 people, in co-operative medical schemes Sender (1992). I have also discussed the substan- with 52 villages containing 48,000 people, in tive issues involved in judging the performance of private payment schemes” that, in that context, postreform China in health care and mortality. “health insurance reduces the crude death rate by The issue is not whether economic growth is (a) 14 per cent” (p. 18). quite unimportant in reducing mortality rates, or

These issues are attracting attention within (b) a complete solution of it. It is neither. We China itself. A Ministry of Health Survey in 1988 have to understand how it works, what it does reported that 20% of the rural households were achieve, and what problems it cannot handle well unable to seek health care when they were ill. on its own. Sixteen percent reported that members of their It is also not a question of simply supplement- household failed to receive needed in-patient ing the picture of overall economic growth with medical care because they could not afford the that of income distribution or income-based c0st.X measures of poverty. As we had noted in Dreze

Those involved with public health issues in and Sen (1989), in the very period for which we China have been concerned about these prob- were concerned about possible problems in lems in recent years. (On this subject see also health delivery, there was a tremendous reduc- World Bank, 1984; Jamison, 198.5; Baumgartner, tion in the number of rural Chinese below the 1989; Henderson et al., 1992a, 1992b; Popkin et poverty line of 200 yuan (p. 216).” The issue is al. 1992, among other contributions.) For ex- command over health services, and it requires us ample, Henderson (1990) notes that “the most to go beyond the income-based analysis of significant result of the reforms in rural areas was growth and distribution to the particular question the demise of many cooperative insurance proof public health measures and entitlement to grams,” with the coverage coming down from medical care. ‘(’ 68.8% of the villages in 1980 to 5.4% in 1985, Nolan and Sender are anxious to defend the rising again to 10% in 1987 (p. 269). This accomplishments of post-reform China, and they combined with an increase in the charge for have filled their paper with favorable data and medical care (“between 1980 and 1985 the statements even in fields which are not involved charges for medical care doubled,” Henderson, in the present dispute. They provide fairly 1990, p. 271), makes the issue of entitlement and comprehensive praise - even pointing out how access a far from trivial one, even with an large a subsidy the central government has given expansion of average availability per capita. to Tibet (Section 2d). It is not obvious that

There is clear evidence of an increase in some uncritical admiration is the most effective way of diseases in rural China (such as hepatitis, epide- helping China at this time. In the past, Chinese mic hemorrhagic fever, and in the early 1980s government policy has received eloquent support dysentery), even though the incidence of other from admirers abroad, even for policies leading diseases went down. Henderson (1990) considers to - and prolonging - the gigantic famine of whether “the persistence or rise in infectious 1958861. Critical scrutiny has a role that venera- disease” can be taken “as an indicator of negative tion cannot usurp.


NOTES

1. In their abstract, presumably forthcoming in the Journal of Economic Lirerature, they present the same

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deluding summary: “Sen’s recent work has emphasised the ineffectiveness of economic growth in achieving fundamentally important human ends.”

2. See Meisner (1986), pp. 451-458, and other standard accounts.

3. See also Hussain and Stern (1990), who go particularly into the question of changing age composition and the rising average age of the Chinese population. Also see Knight and Song (1991).

4. There have been several new sources of data, following the 1982 census and the 1982 one-per- thousand fertility survey (by the State Family Planning Commission). including: the 1987 1% intercensus population survey (by the State Statistical Bureau), and the 1988 two-per-thousand fertility survey (by the State Family Planning Commission). On the changing state of Chinese demography, see Lavely, Lee and Feng (1990).

5. There seems to be firmer evidence of a significant decline in the mortality rates of adults than of children, between the early and the late 1980s.

6. For example, they say: “The general level of ‘collective retentions’ (from which welfare expendi- tures are financed) did fall as a proportion of total rural

income, but collective retentions per capita in real terms increased by almost 75% during 1980-88.” The diagnosis of “this impressive increase” of per capita collective retentions relates to what they describe as “a decline in the rural population (from 796 million to 537 million during 1980-88)” (Section 2~). But there was no such fall in the rural population, only a change in the definition of rural and urban population - a change that the recently published 1991 Statistical Yearbook has already modified.

7. See Sen (1981) and Dreze and Sen (1989).

8. For these and other accounts reinforcing these concerns, see Henderson et al. (1992b), p. 2.

9. See also Riskin (1992). The poverty reduction is mainly due to the growth of aggregate income. Khan et al. (1992) indicate some evidence of an increase in the inequality in income distribution during the 1980s. but note that this income inequality is “less than in most rural societies in developing countries of Asia,” even though “greater than in Taiwan and South Korea and about as great as in India” (p. 63).

10. See Dreze and Sen (1989). On related general issues of ingredients of basic human capabilities, see also Sen (1985) and Griffin and Knight (1989).

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