Tuesday, September 30, 2014

Social democracy succeeds on the strength of its policies, not because of cultural superiority

Image: Flickr user Visa Kopu snaps a photo of her maternity benefit (or "baby box"), sent to every pregnant mother in Finland shortly before her delivery. (source)



This series examines commonly held, racist views on social policy. Part 1 examined the racist idea that social democracy can only work in society that is already harmonious, wealthy, and egalitarian. Even a cursory look at the history of Finland in the early 1900's--desperately impoverished, war-torn, oppressed by occupying armies, society shattered by a brutal civil war--quickly makes these arguments untenable. It also exposes them as racist. Part 2 examined the racist claim that social democracy only succeeds in a homogeneous society. This claim is made untenable (in part) by the experiences of Sweden, which is--by many measures--one of the most diverse nations in Europe. Clearly, minorities are not so evil that their mere presence destroys welfare states. Rather, this view reflects our own racism; when we see statistics that the Swedish educational system is among the very best in the entire world, we assume that there cannot be any students there who aren't white.

This post--part 3--begs the question: If racial, cultural, or genetic superiority cannot account for the success of social democracy--what can?

For this post, we will focus on social democratic child welfare policies (especially infant mortality and childbirth attendance) as an instructive example.

Why do these policies work?
As I've written before, there is no question that social democratic policies are successful. The social democracies as a group have led the developed world in all quality of life indicators, particularly infant mortality and life expectancy, while simultaneously (as a group) leading the developed world in low unemployment and high rates of economic growth. There's no question that the policies work. The question is: why?

The "why" question is of the utmost importance because the conditions of the Scandinavian social democracies in the first few decades of the 1900's--especially Finland--resemble underdeveloped countries in Latin America, Africa, and Asia today. Though prosperous now, the Scandinavian social democracies had endemic poverty and catastrophic quality of life indicators in the early 1900's. For example, Finland's infant mortality rate peaked in the 1930's at a staggering 90 deaths per 1000 live births, which is comparable to the worst infant mortality rates in the world today:


At three deaths per 1000 live births, Finland currently has one of the lowest infant mortality rates in the world. Indeed, the Scandinavian social democracies today have some of the best quality of life indicators in the entire world, even though much of the rest of the developed world had a head start. Is there some reason why policies that worked so well in Scandinavia could not work in the Central African Republic or Mali?



In other words, if social democracy only succeeds in Scandinavia because Scandinavia is a special place, then social democratic policies should never be attempted in underdeveloped countries or poverty-stricken areas of the developed world. If these policies can only succeed in a special place, they would fail anywhere else.

The importance of this question cannot be understated. Real human lives are on the line. People of all ages may needlessly die if that country's policy makers are wrong about what policies are the most effective at reducing these tragic outcomes.

Our question thus becomes: What makes the success of the Scandinavian social democracies possible? A superior society, in which any social policy model would be effective? Or superior policies, which would succeed in any society?

The superior societies argument
I didn't have to look far for examples of the superior society view, as it is the dominant, largely unchallenged consensus on this issue. The following blockquote is the most reputable expression of this view that I could find. Two Ivy League social policy researchers, Elizabeth Bradley (Yale) and Lauren Taylor (Harvard), recently wrote a book comparing the American social welfare system to those of other countries, including Scandinavia. In an interview with Adrianna McIntyre of Vox, they make the case that their findings suggest that there is something special about Scandinavian society that makes social democratic policies impossible to transplant into other societies:
[In Scandinavia, t]he government grew out of a feudalist system where the feudal lords really had an interest in caring for people we might call "serfs." The underprivileged were seen as an integrated part of the economy. There was an interest on the part of those who had means to care for those who didn't.

There's  another interesting hypothesis that is somewhat connected to this: they don't have a very vibrant church community in Scandinavia. There was never this organic religious community to spawn a nonprofit system where responsibility for the underserved could be outsourced. The state could not be let off the hook in that way.

These are hypotheses, but they're historically grounded — it's interesting to think about how deep some of these attitudes toward government can run...
Looking elsewhere, we thought the ideas in Scandinavia were very interesting. But can we really staple those into the United States? Maybe not, because it's not just the strategy they're using today; that strategy is sitting on a historical bedrock of greater collectivism. Culture and underlying values are pieces of this puzzle.
Let's take a closer look at their arguments.

An unspoken rule about discussing the history of social policy is that utterly evidence-free speculations get a free pass as respected, reasoned analysis. Their first evidence-free theory, with its faux-historical veneer, is very racist. They argue that Scandinavian society is simply more caring about their less fortunate citizens. Even if the root of this cultural superiority is not definitively known, American society is simply inferior, as Americans are inherently less concerned for the well-being of others. Though they don't say so, the same by extension must also be true in sub-Saharan Africa or Latin America. Social democracy cannot be a serious proposal in these areas--not when they lack the Scandinavians' inherent altruism.

As for a potential root of this superiority, they suggest that Scandinavian social democracy developed directly from Scandinavian feudalism, an absurd claim that McIntyre leaves unchallenged. To begin, what happened in the centuries between feudalism and the full implementation of the Scandinavian welfare states in the 1980's? One gets the sense that a strong social welfare system develops spontaneously out of an inherently caring society: political struggle was not necessary, the welfare state was built seamlessly, Finland never fought a civil war over social democracy, and striking workers weren't assassinated by government soldiers in Sweden.

Additionally, most of Europe and Japan have feudal pasts. Why are these places not social democrat? How could only Scandinavian feudalism lead to social democracy? Similarly, their rosy view of feudalism seems awfully reductive; the relationship between violent lords and their near-powerless serfs was fundamentally exploitive and oppressive, not caring and concerned.

Bradley and Taylor are correct that social democracy eventually followed Scandinavian feudalism. But an extremely violent, imperialist, genocidal Swedish monarchy also grew out of Scandinavian feudalism. Sweden is certainly one of the most evil countries to ever exist. Among their long list of atrocities, the Swedish army was responsible for a great deal of violence and disruption during the Thirty Years War in Germany in the mid 1600's, in which 25-40% of the German population perished directly from violence or from famine resulting directly from the chaos. Shortly thereafter, Sweden invaded Poland simply because they didn't approve of the Polish monarch's religion; a third of the population of Poland died in this conflict, mostly due to Swedish violence. This war easily trumps the devastation done to Poland in World War II; in Warsaw alone, 90% of the population was either killed or fled the violence. The path from feudalism to social democracy would seem to be more circuitous than implied by Bradley and Taylor.

Bradley and Taylor's other explanation--the current lack of a vibrant church community--is totally incredible. The decline of the role of religion in Scandinavian society is a development that occurred after the rise of the social democrats in the 1920's, not before. And, it's not hard to find other places in the world lacking a vibrant church community. Why shouldn't any other part of the world without a vibrant church community also be a social democracy? This cannot possibly be causative. (Though causality likely runs the other way. A comprehensive public welfare state could easily explain the lack of a vibrant religious-based nonprofit social welfare sector.)

Indeed, the burden of proof for the special societies argument is enormous. I wrote previously about Kerala, a thriving social democratic state in India. If Scandinavia is so special, how were these policies implemented with such resounding success in a single state in India, and no other Indian state? Certainly neighboring states in India are as culturally similar to Kerala as Finland is to Iceland. Similarly, the previous post on this issue focused on how the increasing diversity has not fundamentally altered the welfare systems of Scandinavian countries. Austria, too, is a thriving social democracy outside of Scandinavia.

More damning, however, is the experiences of the two American social democratic programs, Medicare and Social Security. If social democratic programs cannot be simply "stapled" into the United States, why have these two social democratic programs--essentially indistinguishable from their Scandinavian counterparts--thrived in the United States for several decades? Not only are these programs widely successful, they are extremely popular. Even conservative Republican voters support these social democratic programs overwhelmingly. Serious intellectual contortions need occur to explain how the United States has a "historical bedrock of greater collectivism" towards the elderly, but not anyone else (including innocent children). This all argues in favor of the policies being superior, not the society.

Again, the above block quote isn't from ignorant Internet comments--it's from well-respected American scholars of social policy. This racist view--however untenable--is widely held and respected.

This view is so widespread because it certainly seems reasonable. After all, the Scandinavian populace are generally strong supporters of their welfare states. Voting majorities of other countries could not possibly conscience the increase in taxes necessary to support such a large welfare state; since the Scandinavians do consent to such taxation in order to better society as a whole, they must be a superior race of people.

But if we actually look at the history of social democracy in Scandinavia, a much different picture emerges. There are two main problems with the idea of Scandinavian culture being inherently superior or more caring. We will address these issues in turn, using Finnish child welfare policy as an instructive example.

If Finnish culture is inherently more caring, why did it take half a century to implement child welfare policies?
The first problem becomes obvious if we take a very wide historical perspective of the development of the Finnish welfare state, spanning several decades and several different programs. If the Finnish social welfare state grew out of some inherent superiority of Finnish culture, then the Finnish social welfare state should have been rapidly implemented. If Finnish culture is so inherently caring, then the public should have clamored to pass into law the entire social democratic welfare state in a very short period of time following the transition to democratic rule.

It is obvious, then, that Finnish society is not superior. Finnish child welfare policies were implemented slowly and incrementally over five decades. The first Finnish social democratic child welfare policy was maternal health (discussed below), first implemented in 1927, one year after the election of the first social democratic prime minister and a full decade after independence from Russia. Finland waited 22 years before taking its next step forward in child welfare: in 1949, Finland became the first country in the world to provide free meals to children at school. Universal child care services were not implemented until 1973. Finland first required its elementary school teachers to have masters degrees in the 1970's. Though not a social insurance program, would a truly superior society have waited until 1983 to enact a law prohibiting all forms of physical punishment of children? This time line clearly discredits the view that social democratic policies can stem only from an inherently caring, harmonious, superior culture. An inherently caring culture would have demanded their political system enshrine these policies in legislation as soon as possible; it should not have taken over half a century, beginning a decade after political independence from Russia.

Ordinary Finns initially fought against social democratic maternal health policies
Even a cursory look at the time line of the development of the welfare state casts significant doubt on the superior societies argument. But this is also true if we study in greater detail the development of a single Finnish social welfare program.

As an instructive example, we will examine how Finnish society reacted to the implementation of professional birth attendant policies designed to lower the incidence of maternal and infant mortality during birth. The information for this section comes from a book called Birth by Design, which traces the development of maternal health policies in different countries around the world. For clarity, I am summarizing their section on Finland here; if you want longer blockquotes for more information (which really did not fit into the format of this post), see this post or the book itself.

For our purposes, the story begins in the 1920's, before Finland was a social democracy. Finland's Social Democrats realized that a stunning number of pregnant women and newborns were dying during childbirth. Many of these deaths were completely preventable. The technical know-how existed to prevent many of these deaths--if only a properly trained medical provider could attend births. So, once in power, the Social Democrats required municipalities to provide a professional birth attendant for every birth, paid for entirely by the federal government. Obviously, if the problem comes down to not enough funding for professional birth attendant services, then providing adequate funding for every delivery to have a professional birth attendant should be the solution.

Unfortunately, the high aspirations of this policy immediately collapsed under fierce resistance from Finnish society, especially in rural areas (most of Finland's population lived in rural areas at this time). Resistance from ordinary Finns was so strong that the policy was a near-complete failure. Though services were offered completely free of charge, the vast majority of intended beneficiaries (over 90% in rural areas) refused to participate. This fierce resistance continued for over a decade, when the Social Democrats fundamentally redesigned the program with the explicit goal of overcoming society's resistance.

Imagine how frustrating this must have been for the early Finnish Social Democrats. Years of blood, sweat, and tears had been poured into making this policy a reality. No one got rich off or powerful off of this political campaign to prevent deaths in childbirth--it was purely for public benefit. Yet women and infants continued to die needlessly in childbirth because society at large refused to cooperate. This is not a superior society. This is an average society that fears change and sometimes fights against its own best interest. Obviously, a superior society would not have--as the Finns did--make a choice that resulted in the unnecessary deaths of thousands of infants and mothers, rather than participating in a new program designed to help them. Human nature fears change, and not even the Scandinavians are different.

The superior policy argument: How the Social Democrats turned a failed policy into one that succeeded
Obviously, Finnish society is not superior. But the initial design of the birth attendant policy wasn't superior, either. Though the birth attendant services--when they were actually used--were effective at preventing maternal and infant death in childbirth, the policy was a failure because families refused to use it. Gaining society's trust is an essential part of a policy's success, and a policy that can't do so--no matter how well designed otherwise--needs refinements.

Unfortunately, it took the Finnish Social Democrats more than a decade to figure this out. Once they learned from their mistakes, they were able to craft an excellent social policy that better served the needs of the intended beneficiaries. More importantly, they learned work with--rather than against--society's resistance.

The Social Democrats accomplished this in the late 1930's by expanding the birth attendant policy to include (1) prenatal care by professional maternal health experts before birth and (2) an in-kind* maternal benefit after birth. The in-kind benefit included all the supplies a family would need to welcome a new baby into the world--clothes, bottles, diapers, etc, all packed into a large box with a padded bottom.

The advantages of these programs are obvious. Since so many Finnish families were so poor, the basic supplies of the in-kind benefit helped cut infant mortality--particularly the padded box, which served as a makeshift crib to prevent infant cosleeping deaths. And, the prenatal health program was also designed to prevent infant and maternal deaths--though the obvious problem was that if Finnish society didn't trust a birth attendant, they wouldn't trust a prenatal care professional.

However, the key breakthrough of these new policies was that the maternal benefit was conditional on the participation in the prenatal care program. If a family did not participate in prenatal care throughout the mother's pregnancy, families would forfeit their maternity benefit. This prenatal care was provided in mothers' homes by professional birth attendants. In this way, in the course of providing in-home prenatal care, the medical providers who would later attend the birth (and quite possibly save the life of the mother or infant) had a few months to gain the trust of families before a mother actually went into labor.

The effect was dramatic. Though the maternity benefit was not conditional on professional birth attendance, in a few short years, nearly 100% of newborn infants were delivered by a professional birth attendant. The combination of prenatal care, the in-kind maternity benefit, and professional birth attendance resulted in a spectacular drop in infant mortality and bad birth outcomes (see the next section). Finally, the Finnish Social Democrats were able to develop a superior policy that had its intended effects.

The essential elements of a superior social policy
The development of the entire Finnish maternal health program is a classic lesson in social policy design. Eventual success was due to two indispensable elements of effective social policy design:


Effective services: Today, Finland has one of the lowest infant mortality rates of any country on earth. Though I could not find data about deaths in childbirth, the decline in infant mortality rates following the institution of the maternal health programs is incredible:**


For the birth attendant program, effectiveness means that the chances that mother or child die during birth are slashed when a birth attendant is present. But effectiveness also means that the intended beneficiaries actually use the program. A program with a 100% success rate that reaches only 1% of the intended beneficiaries is not an effective program. In designing social policy, initial societal resistance needs to be considered natural and inevitable; a good policy anticipates this resistance and designs ways to work with it.*** Unfortunately, it took over a decade for the Finnish Social Democrats to realize this; until they did, women and infants continued to tragically die preventable deaths during childbirth. Professional birth attendants and the maternity benefit thus worked together to ensure that services delivered were effective and that services were not underutilized.

Universal services: An essential strength of social democracy is universality. With temporary exceptions, all maternal health benefits were universal. Every expecting mother, no matter how rich or how poor, received the same benefits and services. Because everyone benefited from universal social welfare programs, those programs quickly become valued by a large cross section of society. Huge majorities--rich and poor alike--personally benefit from and thus value these policies. Such popularity translates to an energetic majority voting population, highly motivated to protect these programs with their votes. Indeed, the maternal benefit policy was so popular that to this day, it still exists, essentially unchanged since first instituted in the 1930's:
For some families, the contents of the [maternity benefit] box would be unaffordable if they were not free of charge, though for Vayrynen, it was more a question of saving time than money.

She was working long hours when pregnant with her first child, and was glad to be spared the effort of comparing prices and going out shopping.

"There was a recent report saying that Finnish mums are the happiest in the world, and the box was one thing that came to my mind..."
The universal birth attendant policy no longer exists because it was replaced in 1964 by an even more popular program: universal health care.

The interplay of effectiveness and universality: For social democracy, universality and effectiveness go hand-in-hand. In 1920's and 30's Finland, government birth attendant services were of higher quality and more cost-effectively delivered than those same services delivered by the private market. In other words, those wealthy enough to opt out of the government program by purchasing services in the private market had no reason to do so. All this translates into the appearance of a superior society. Everyone fights for the protection and well-being of everyone else because they understand that protecting all society means protecting themselves. As a group, not even the wealthy oppose the welfare state because it delivers high quality services unavailable elsewhere. The popularity of social democratic programs stems from their effectiveness and universality--even if Finnish culture no longer remembers the struggle to enact these policies. Clearly, Finnish culture is not superior; effective, universal policies would succeed in any culture.

Like Finland, American society is also average
Clearly, the history of the Finnish birth attendant policy argues persuasively that an average society slowly came to embrace a superior policy only after experiencing first hand its effectiveness. But the same is also true of the implementation of America's social democratic Social Security program. When Social Security was first implemented, the general populace was skeptical of the program and did not want to participate ("DeWitt also argues that many farmworkers and maids themselves were opposed to being covered."). Now, Social Security is the most popular thing the federal government does, supported overwhelmingly by American liberals and conservatives alike. Clearly, Finnish society is not so different from American society.

The obvious contrapositive of both of these examples is that implementation of other social democratic programs is likely to follow the same trajectory: the policies will likely be unpopular and distrusted at first, then become popular once people realize how effective the programs are. Hence, America's social democrats can expect decades of painstaking voter mobilization before politicians can be convinced that it is in their best interest to pass new social democratic policies. This will only be accomplished through decades of arguing, persuading, and mobilizing average voters. Again, this is no different than the experiences of Finland's social democrats throughout the 1900's. Only after decades of mobilization starting in the late 1800's were the Finnish Social Democrats able to implement the birth attendant policy in 1927; after a parade of mistakes, lessons learned, and improved policies, universal child care was finally passed in 1973.

If you actually believe false promises from Republicans or Democrats of rapid results, this is not the place for you. Come back in a few years when you learn that gaining the consent of a society to implement strong social policy takes time.

Conclusion
When we paper over history and assume that social democracy only succeeds in a superior society, we do a grave injustice to underdeveloped countries and poverty stricken regions in the developed world. As we have seen, social democratic policies are the most effective at lowering infant mortality and improving other quality of life indicators. Cultural superiority arguments thus rule out the most effective social policies in the places that most desperately need them. We advise developing countries and impoverished areas in the developed world not to use the most effective policies based on the racist view that their society is inferior, that their evil citizens--African, Asian, Latin American, or American minority groups--somehow preclude successful implementation of social democratic policies.

This isn't a hypothetical concern. In the interview I blockquoted above, the two social policy scholars took their baseless speculations to their natural conclusion:
I would pick out three lessons. The first is that a lot of our current situation is related to root cultural values underlying the history that has brought us to this place.

Looking elsewhere, we thought the ideas in Scandinavia were very interesting. But can we really staple those into the United States? Maybe not, because it's not just the strategy they're using today; that strategy is sitting on a historical bedrock of greater collectivism. Culture and underlying values are pieces of this puzzle.
The mind boggles at just how much is wrong in these two short statements. There was no "historical bedrock of greater collectivism" when the Social Democrats were first elected in Finland. Try to square these claims with part 1 of this series: the rise of Finnish social democracy in the 1920's from the ashes of a brief but brutal civil war, where tens of thousands died from mistreatment in prison camps, a generation of orphans was created, and over 1% of the population died overall. "Culture and underlying values" at that time ran fought against collectivism, not with it. If there is current "culture and underlying values" of altruism, or a "bedrock of greater collectivism", it surely didn't exist when social democratic policies were first instituted in Finland.

And--to repeat arguments made above--if social democratic policies cannot be simply "stapled into" the United States, how are Social Security and Medicare--essentially indistinguishable from their Scandinavian counterparts--so successful and popular? If superior culture drives the welfare state, how is a single state in India social democratic, and none of its neighbors? Why is Austria social democratic?

Clearly, these policies could work in any place, no matter how bitterly divided--simply because these policies have already worked in Finland and the other social democracies. Divisions in the United States and countries around the world may seem insurmountable, but--as we saw in part 1--they certainly do not exceed those of 1920's Finland.

In short, we do a tremendous disservice to societies around the world when we assume social democracy can only succeed in the prosperous, egalitarian, harmonious Scandinavian societies we see today--and not the impoverished, violent, oppressed, profoundly divided societies they once were. Good social policy succeeds in any society; high quality program design isn't magic.



Other posts in this series:
Part 1
Part 2
Part 3 (this page)
Part 4



*An "in-kind" benefit is a benefit of goods or services--like baby clothes, bottles, diapers, etc. The other kind of benefit is a cash benefit, like American Social Security checks that get mailed out (or direct deposited) to retirees each month.

**Spikes in infant mortality are due to two separate wars with the Soviet Union during World War II; see first post on this issue. It should be noted that the maternal benefit program continued uninterrupted during both wars with the Soviet Union. The need for the maternal benefit was seen as especially important given the refugee crisis created by both wars and their aftermath. The political system decided that mothers and infants were not to be casualties of the war. A handful of countries have lower infant mortality rates than Finland, but these countries did not have Finland's catastrophic infant mortality rates in the first half of the 1900's. Our interest here is Finland's rapid transition from nearly the worst infant mortality in the world to nearly the best, and how this can be repeated in other countries.

***I argue in a forthcoming post that this is one of the greatest weaknesses of Obamacare. UPDATE: This post, in section titled "Obamacare and automatic enrollment"

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