Democracy does not die in the darkness so often anymore. It dies in the light, one election at a time, with voters embracing the populists and autocrats who promise to cut the red tape and deliver the better life that democracy has failed to provide.
It was not midnight military coups or dark backroom deals that brought strongmen to power in Nicaragua, Turkey, and Venezuela, former democracies that have joined the ranks of the world’s autocracies. Everyday frustrations over high health-care costs, poorly performing schools, and corrupt politicians drove voters in those countries to elect populists. Once in power, those populist leaders openly and steadily undermined the fair elections, free media, and institutional restraints that are the hallmarks of democracy, cheered on by supporters hungry for results.
The result of this trend has been the global rise in the number of countries undergoing autocratization, or significant declines in the quality of their democracy. At the same time, the number of nations that are democratizing—or experiencing significant improvements in the quality of their democracy—peaked in 1994 soon after the end of the Cold War and has been falling ever since (see figure below). In some nations, like Nicaragua and Turkey, the extent of that autocratization has advanced so far that those nations are now considered electoral autocracies, countries in which elections are still held but under conditions that prevent opposition parties from fairly campaigning or that keep votes from being freely cast or accurately counted. According to recent research from Anna Luhrmann and Staffan I. Lindberg from the University of Gothenburg’s Varieties of Democracy (V-Dem) Project, more than two-thirds of this rise in electoral autocracies is due to the gradual deterioration of former democracies. This year, the V-Dem Project designated twenty-four democracies as autocratizing. The United States is on that list.
Voters may turn to autocracy for promises of a better life, but, at least with regard to health, those expectations are not fulfilled. Life expectancy has declined 2 percent on average in former democracies that have recently transitioned to autocracy (Honduras, Nicaragua, Turkey, and Venezuela) relative to democracies that have not made that transition (see figure below). The unhealthful effects of autocracy remain robust even when accounting for economic differences and excluding Venezuela, with its collapsing health system.
Without the pressure of fair electoral competition or accountability to a free media, autocratic leaders have less incentive than their democratic counterparts to do the hard work of sustaining health-care infrastructure and improving care for chronic diseases. Instead of adopting measures that improve the health of the population, autocrats in nations such as Turkey have exploited ethnic and class divisions and resorted to patronage to keep power.
Autocratization is hazardous to health. Part of its toll on longevity might be the result of missing out on the benefits democracy can make to reduce deaths from noncommunicable diseases, which are rapidly increasing in many low- and middle-income nations. A nation’s democratic experience—a measure of how democratic a country has been and for how long—matters more than its gross domestic product (GDP) in the reductions in deaths from cardiovascular diseases, transportation injuries, cancers, and other noncommunicable diseases. Cardiovascular disease is the leading cause of death worldwide, killing more than seventeen million people in 2015. Stroke, cancers, and other noncommunicable diseases are responsible for more than two-thirds of deaths globally, including those of eight million people under the age of sixty in poorer countries. By 2040, noncommunicable diseases will affect roughly the same share of the populations in many low- and middle-income countries as they do in the United States.
Previous research estimated that increases in democratic experience averted sixteen million deaths globally between 1995 and 2015 from cardiovascular diseases alone. The figure below indicates which countries benefited from the health improvements associated with democracy. The Baltic states, Brazil, Mongolia, Poland, and South Africa experienced some of the greatest improvements in health as democratizing states. Tragically, some of those nations, including Brazil and Poland, may now be drifting toward autocracy.
Free and fair elections appear to be particularly important for these improved adult health outcomes, most likely because they increase government accountability and responsiveness. The health benefits of democracy are greater in nations that maintain genuine electoral competition and have experienced at least one transfer of power. Nations such as Botswana and South Africa that held multiparty-elections between 1995 and 2015 but did not experience a turnover in their ruling party did not fare as well in reducing deaths from cardiovascular disease as those nations such as Uruguay and Zambia that had at least one turnover (see figure below). However, having multiple turnovers of the ruling party did not increase the positive or negative effects of having experienced at least one transfer of power.
Elections and the health of a nation’s people are increasingly inseparable. Democratic institutions and processes, particularly free and fair elections, can improve population health, especially with regard to cardiovascular and other noncommunicable diseases. Voters should remain wary of populists who promise to deliver better health by undermining the accountability, messy compromise, and slow consensus-building that democracy requires.
To understand the methodology used, see this annex [PDF].
This interactive was made possible by a generous grant from Bloomberg Philanthropies. The statements made and views expressed are solely the responsibility of the authors. We thank Maria Teresa Alzuru and Kevin Lizarazo for their assistance with this interactive. The Council on Foreign Relations takes no institutional positions on policy issues and has no affiliation with the U.S. government.