The past two hundred years have borne awesome changes to the world (in the definitional sense of the word): world population has septupled – septupled! – and, looking at the way lives are lived now, anyone living in 1814 would likely conclude (not wholly incorrectly) that we are Sorcerers Practicing Black Magick. Technologically, socially, and economically, the past 200 years have been vastly different than the preceding 200. Or 1,000, for that matter.
How did a few nations break thousands of years of (relative) constancy and become significantly wealthier and healthier than ever before? Why didn’t, and haven’t, others? What’s happening now, and what can we expect to happen in the future?
Angus Deaton, a professor at Princeton University, wrote a masterclass of a book, The Great Escape, dissecting these questions. I can’t recommend it highly enough to anyone interested in health and wealth; medicine and economics; the past and the future.
The book isn’t actually a book; it’s more like a book and a chapter-length op-ed, and it’s worth reviewing each separately. The book, Chapters 1-6, is the most complete accounting of the recent changes in health and wealth in the world that I’ve read. The op-ed makes the case that foreign aid weakens recipient governments – especially in Sub-Saharan Africa, where in many countries it approaches three-quarters of government expenditures – and as a result harms the people it putatively tries to help (though “tries to help” does a lot of work in that sentence, and Deaton argues it often isn’t about helping them but us).
The first few chapters walk through the truly shocking increases in health many wealthy societies have witnessed during the past few generations. This “aging of death,” as Deaton delightfully calls it, started around the 1850s in Western countries and eventually filtered down to less-developed regions in the 1950s and thereafter; it continues to this day.
As Deaton points out, life expectancy is a confusing metric, and kind of a bad one at that. Take the fictional country of Macronesia: because of a genetic defect, half of its population dies at birth, and half lives to be 100 years old. It’s average life expectancy is, therefore, 50 years – but no one lives to be just 50, and those that make it past their first day have 100 years of life left. 50 is, in this context, a meaningless number. But it’s Macronesia’s life expectancy just the same.
And so it is with many real countries that have intolerably and unconsciously high infant and child mortality rates. Think America at the turn of the 19th century, when life expectancy was something like 40 (a generous, speculative figure that is almost certainly on the high side). But that’s because so many kids died. To pull a few (admittedly non-random) examples of lifespans we would consider long today, George Washington wasn’t 40 when he died; he was 67. Benjamin Franklin, John Adams, and Thomas Jefferson were 84, 83, and 90, respectively.
(Because I just have to: in one of history’s great coincidences, Adams and Jefferson – one-time sworn political enemies who nevertheless developed a long, deep correspondence by pen in the gloaming of their post-presidential lives – died on the same day in 1826 – the Fourth of July. The 50th anniversary of the official signing of the Declaration of Independence. Because of course.)
Another problem with life expectancy: as an American white male, my life expectancy at birth in 1987 was 72.1 years – but that was an outdated figure almost as soon as the ink dried on that year’s actuarial table. Changes in medicine, technology, and policy over my lifetime will almost certainly mean that my (American, white, male) peers and I will live, on average, far longer – even past 100.
Though he (rightfully) questions the use of life expectancy as a metric in and of itself, the massive uptick in it is because far, far fewer children are dying than before, and that this is because of public health measures:
The major credit for the decrease in child mortality and the resultant increase in life expectancy must go to the control of disease through public health measures.
Because of public health measures, when we talk about countries, we no longer talk about neonatal and child deaths per 1,000 live births; we talk about them in numbers greater than that by two orders of magnitude: 100,000.
As a result, in America, life expectancy increased from 47.3 in 1900 to 77.9 in 2006. He puts it more colorfully than I could:
One way in which the transition is sometimes summarized is to say that diseases move out of the bowels and chests of infants into the arteries of the elderly.
The second half of the book describes the unprecedented economic growth that began in the 1800s and continues today. I won’t get into it much (if there’s any story here you already know, it’s this one), and only will make a few points about measurement.
Deaton convincingly argues that defining and measuring poverty across countries is much more difficult than most casual observers realize. A dollar goes further in India than in the states, and even the calculation to account for this – the wonkily-named “Purchasing Power Parity” – is flawed in obvious and predictable ways. Defining poverty is also difficult in America itself; the poverty line was first chosen then rationalized, and has always been politically fraught.
Gross Domestic Product, or GDP, is a problematic measure, too (and a recent one, as Planet Money helpfully discussed on a recent podcast episode). As Robert F. Kennedy pointed out, it measures much of what we don’t necessarily want, and little of the important, ephemeral things in life.
(Deaton doesn’t even dive into the difficulties about figuring out the GDP of a country – especially a poor country – a monster of a problem in itself).
At times during the book part of the book, Deaton is a bit of a broken record – mentioning too many times to count that “escapes leave people behind, and luck favors some and not others”– but this is a minor sin easily overlooked.
The op-ed at the end is, to put it mildly, polarizing. Deaton is an intellectual monster in the field of development economics, so his firmly planting a foot in the “anti” camp made waves. I won’t get into the arguments much – there’s simply too much to cover – but will give a short summary and a note of admiration.
His argument basically rests on the idea that foreign aid – even the 100% benign, apolitical aid, if it exists (though there’s reason to believe it doesn’t) – necessarily distorts the policies and actions of recipient governments. Governments that are strong don’t need the aid, he argues, while governments that aren’t strong (read: corrupt, authoritarian, or both) will be hurt by the aid. In other words, think of it like the Halstedian “radical mastectomy” of aid: it’s used when it either can’t help anyway or isn’t needed in the first place, and causes severe trauma either way.
(For more on radical mastectomies and cancer, read The Emperor of All Maladies, a wonderful book that I reviewed here).
Deaton does mildly argue that aid directed towards the provision of certain types of health care (safe water, sanitation, pest control) can be, on net, a capital-G Good thing. And he voices approval for certain types of indirect aid: funding research into Neglected Tropical Diseases; advocacy for policy changes that promote migration and trade; removing harmful rent-seeking subsidies; et cetera But overall, he’s quite skeptical of direct-to-consumer aid.
Deaton’s op-ed chapter is admirable for its bluntness and for its acceptance of a hard truth: getting rid of aid may be normatively the best for the long-term fate of low-income countries, but in the short-term this is both impossible – does anyone really think USAID and the World Bank are just going to disappear? – and has serious immediate consequences (people will die). But he argues for it anyway, and kudos to him for having the bravery to do so.
This book – and its accompanying op-ed – is fantastic. Full stop. Buy it now.