Development as Freedom is a popular summary of economist Amartya Sen's work on development. In it he explores the relationship between freedom and development, the ways in which freedom is both a basic constituent of development in itself and an enabling key to other aspects. Development as Freedom is a 1999 book about international development by the economist Amartya Sen. Amartya Sen was the winner of the 1998 Nobel Prize in Economics. His book argues that economic development entails a set of linked freedoms: Political freedoms and transparency in relations between people.
This book was a revelation to me and is likely to be regarded as one of the most important books of the current era. Sen's main objective is to bypass (and critique) the widely held current ideology that the best means of ‘development' is to increase the rate of economic growth. In contrast he argues that the main purpose of development is to spread freedom to the unfree. In doing so he claims back two words that have functioned as key parts of the political and economic orthodoxy of the past few decades: ‘development’ and ‘freedom’. Most people would agree that the main aim of life is not just to make money (or to accumulate Frequent Flyer Miles), and that this is simply a means to an end. However, few people, and fewer economists, would agree on what the real ‘meaning of life’ is, or for that matter what the purpose of ‘development’ is.
This has left the field wide open for the current dominant ideology to equate ‘development’ with economic development and to argue that all the good things in life flow from this. In response to this, some commentators have attempted to add a human face to the current economic orthodoxy, e.g. Through the use of explicitly economic terms such as ‘human capital’ and ‘social capital’ which stress the importance of human beings and their social networks in enhancing economic growth.In contrast to this, Sen argues that expansion of freedom is both the primary end and the principal means of development. Sen's approach re-establishes the word ‘freedom’ as referring to the enhancement ‘human capabilities’ which involve processes of decision making, as well as opportunities to achieve valued outcomes, i.e.
The substantive freedom of people to lead the lives they have reason to value and to enhance the real choices they have. This includes the concept of ‘human capital’ (which he explicitly discusses) as well as concepts that have elsewhere been referred to as ‘social capital’, but his approach is much broader than this, in particular, Sen refers to the five distinct ‘instrumental freedoms’ of: 1) political freedom; 2) economic facilities; 3) social opportunities; 4) transparency guarantees and 5) protective security.
These freedoms are complementary and mutually reinforcing. Thus, economic development, which benefits a minority of the population, while being based on the restriction of political freedoms and social opportunities for the majority, is not real development, no matter how it may be reflected in levels of GDP. Even if the majority are not technically slaves, they are denied elementary freedoms and remain imprisoned in one way or another, by poverty, deprivation, political tyranny or cultural authoritarianism. This includes not only countries, for example, in which freedom of speech is explicitly prohibited, but also those in which it is absent in practice because of economic, social or cultural factors.These issues are directly relevant to health, and vice versa, and Sen's book is full of health examples. He includes the familiar examples of countries such as China, Costa Rica and the Indian State of Kerala, which have achieved large increases in life expectancy despite low per capita GDP, in contrast with, for example, the low life expectancy of American blacks. This is commonly assumed to apply primarily to young black men, e.g. Through deaths from violence.
However, it extends to women and to older age groups, and in this respect American blacks are not only relatively more deprived than American whites, but despite their higher absolute incomes, are also absolutely more deprived than the low-income Indians in Kerala and the Chinese. The causal influences include factors such as medical coverage, public health care, school education, and violence.
He also discusses the differing attitudes to health care and mortality in Europe (high unemployment, low income inequality, good access to health care) and the United States (low unemployment, high income inequality, poor access to health care). In light of current debates within epidemiology, his discussion of income inequality and health is particularly interesting, and makes it clear that the health effects of income inequality (to the extent that they are causal) will vary greatly depending on the social and economic context.Sen's approach is striking in that it bypasses (or subsumes) the current economic orthodoxy, rather than attempting to adapt it to social goals. Perhaps there is a lesson here for the field of ‘social epidemiology’, and particularly for the research involving the concept of ‘social capital’ which attempts to discuss, and research, social concerns in economic language and concepts. Although the aim may be to convert the language of ‘orthodox’ economics for the study of social issues, the concept is ultimately of limited use (and in some instances is hazardous to health) because it is a prisoner of the orthodox economic viewpoint which it is trying to adapt.
In contrast, Sen argues that the concept of ‘human capital’ is not inconsistent with the concept of ‘development as freedom’, but never resorts to reducing his arguments to orthodox economic terms or terminology. Rather he regards economic issues as specific cases of the more general concepts that he is considering.Sen has been criticised as not going far enough in terms of analysing the power relations that cause and reproduce underdevelopment. Certainly, he presents a generic argument that does not discuss the differing political systems in the countries that he contrasts, and glosses over many important issues.
There is also the danger that grand abstract concepts may detract attention from the simple reality that most people die as a result of the (neo)material conditions in which they live. Nevertheless, abstract concepts can help to explain why this occurs, why some people's material conditions are different from others, and what can be done about it. In this context, his approach represents a major break with the dominant neoliberal position that is reproduced in most national and international development agencies. It thus represents both a major opportunity, and a major challenge for the epidemiologists who may wish to conduct studies of the issues that Sen articulates.
‘Freedom’ in the sense that Sen has defined it, is extremely difficult to measure, at least in the form that can be summarized in a two by two table. Given the difficulties of measuring similarly ‘fuzzy’ concepts such as ‘social capital’, and the resulting tendency to draw sweeping theoretical conclusions from very limited data, can we do any better with measuring ‘freedom’ as Sen defines it and ascertaining its benefits for health? In any case, a standard two by two table will frequently not be appropriate because health is part of the ‘exposure’ as well as being the outcome.Nevertheless, this represents a failing of current models of epidemiology as much as it represents inadequacies or lack of clarity in Sen's concepts. Tony McMichael's call for us to develop new methods in response to new public health problems is even more appropriate in the ‘development’ context that in the environmental health context in which it was first made. The task for the coming century for epidemiologists will be to study the real determinants of health and the real outcomes for health and development at the global level. This book will play a key role in both stimulating and guiding this process.
This book was a revelation to me and is likely to be regarded as one of the most important books of the current era. Sen's main objective is to bypass (and critique) the widely held current ideology that the best means of ‘development' is to increase the rate of economic growth. In contrast he argues that the main purpose of development is to spread freedom to the unfree. In doing so he claims back two words that have functioned as key parts of the political and economic orthodoxy of the past few decades: ‘development’ and ‘freedom’. Most people would agree that the main aim of life is not just to make money (or to accumulate Frequent Flyer Miles), and that this is simply a means to an end.
However, few people, and fewer economists, would agree on what the real ‘meaning of life’ is, or for that matter what the purpose of ‘development’ is. This has left the field wide open for the current dominant ideology to equate ‘development’ with economic development and to argue that all the good things in life flow from this. In response to this, some commentators have attempted to add a human face to the current economic orthodoxy, e.g. Through the use of explicitly economic terms such as ‘human capital’ and ‘social capital’ which stress the importance of human beings and their social networks in enhancing economic growth.In contrast to this, Sen argues that expansion of freedom is both the primary end and the principal means of development. Sen's approach re-establishes the word ‘freedom’ as referring to the enhancement ‘human capabilities’ which involve processes of decision making, as well as opportunities to achieve valued outcomes, i.e.
The substantive freedom of people to lead the lives they have reason to value and to enhance the real choices they have. This includes the concept of ‘human capital’ (which he explicitly discusses) as well as concepts that have elsewhere been referred to as ‘social capital’, but his approach is much broader than this, in particular, Sen refers to the five distinct ‘instrumental freedoms’ of: 1) political freedom; 2) economic facilities; 3) social opportunities; 4) transparency guarantees and 5) protective security.
These freedoms are complementary and mutually reinforcing. Thus, economic development, which benefits a minority of the population, while being based on the restriction of political freedoms and social opportunities for the majority, is not real development, no matter how it may be reflected in levels of GDP. Even if the majority are not technically slaves, they are denied elementary freedoms and remain imprisoned in one way or another, by poverty, deprivation, political tyranny or cultural authoritarianism. This includes not only countries, for example, in which freedom of speech is explicitly prohibited, but also those in which it is absent in practice because of economic, social or cultural factors.These issues are directly relevant to health, and vice versa, and Sen's book is full of health examples. He includes the familiar examples of countries such as China, Costa Rica and the Indian State of Kerala, which have achieved large increases in life expectancy despite low per capita GDP, in contrast with, for example, the low life expectancy of American blacks. This is commonly assumed to apply primarily to young black men, e.g. Through deaths from violence.
However, it extends to women and to older age groups, and in this respect American blacks are not only relatively more deprived than American whites, but despite their higher absolute incomes, are also absolutely more deprived than the low-income Indians in Kerala and the Chinese. The causal influences include factors such as medical coverage, public health care, school education, and violence. He also discusses the differing attitudes to health care and mortality in Europe (high unemployment, low income inequality, good access to health care) and the United States (low unemployment, high income inequality, poor access to health care).
In light of current debates within epidemiology, his discussion of income inequality and health is particularly interesting, and makes it clear that the health effects of income inequality (to the extent that they are causal) will vary greatly depending on the social and economic context.Sen's approach is striking in that it bypasses (or subsumes) the current economic orthodoxy, rather than attempting to adapt it to social goals. Perhaps there is a lesson here for the field of ‘social epidemiology’, and particularly for the research involving the concept of ‘social capital’ which attempts to discuss, and research, social concerns in economic language and concepts.
Although the aim may be to convert the language of ‘orthodox’ economics for the study of social issues, the concept is ultimately of limited use (and in some instances is hazardous to health) because it is a prisoner of the orthodox economic viewpoint which it is trying to adapt. In contrast, Sen argues that the concept of ‘human capital’ is not inconsistent with the concept of ‘development as freedom’, but never resorts to reducing his arguments to orthodox economic terms or terminology. Rather he regards economic issues as specific cases of the more general concepts that he is considering.Sen has been criticised as not going far enough in terms of analysing the power relations that cause and reproduce underdevelopment. Certainly, he presents a generic argument that does not discuss the differing political systems in the countries that he contrasts, and glosses over many important issues. There is also the danger that grand abstract concepts may detract attention from the simple reality that most people die as a result of the (neo)material conditions in which they live.
Nevertheless, abstract concepts can help to explain why this occurs, why some people's material conditions are different from others, and what can be done about it. In this context, his approach represents a major break with the dominant neoliberal position that is reproduced in most national and international development agencies. It thus represents both a major opportunity, and a major challenge for the epidemiologists who may wish to conduct studies of the issues that Sen articulates. ‘Freedom’ in the sense that Sen has defined it, is extremely difficult to measure, at least in the form that can be summarized in a two by two table.
Given the difficulties of measuring similarly ‘fuzzy’ concepts such as ‘social capital’, and the resulting tendency to draw sweeping theoretical conclusions from very limited data, can we do any better with measuring ‘freedom’ as Sen defines it and ascertaining its benefits for health? In any case, a standard two by two table will frequently not be appropriate because health is part of the ‘exposure’ as well as being the outcome.Nevertheless, this represents a failing of current models of epidemiology as much as it represents inadequacies or lack of clarity in Sen's concepts. Tony McMichael's call for us to develop new methods in response to new public health problems is even more appropriate in the ‘development’ context that in the environmental health context in which it was first made. The task for the coming century for epidemiologists will be to study the real determinants of health and the real outcomes for health and development at the global level. This book will play a key role in both stimulating and guiding this process.