Tag: Child Mortality

Book-Blogging: The Great Escape, by Angus Deaton


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.

USAID Food Bag

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.

Monday Links

With Less Than 1000 Days To Go, How Is Progress on the MDGs Looking? Part One: Health

There are 944 days left until January 1st, 2016. For most, that probably means little else than the official start of Decision 2016, and the thought of another presidential election probably elicits cold sweats, headaches, and flashbacks of a time best forgotten (for at least another six months).

An 'Embraced' newborn at Mbale Regional Referral HospitalBut for the world community, January 1st, 2016 is a big day: the official endpoint of the Millennium Development Goals (MDGs), a set of eight development goals chosen in 2000 and pledged to by all 193 member states of the United Nations. “We only have 1000 days left!” is a powerful clarion call for further action, and to spur it on, the “grassroots advocacy and campaigning organization” ONE recently came out with a long progress report detailing where countries are at.

It’s an at-times encouraging, at-times depressing look at what has been accomplished and how much is left to do. I’m going to take this in chunks and first focus on the “Health-Related MDGs:” 4, 5, and 6, dealing with child mortality (reduce by two-thirds the under-5 mortality rate), maternal mortality (reduce by 75% the Maternal Mortality Ratio), and HIV/AIDS (halt and reduce spread of HIV/AIDS), respectively[1]. I put together this graph to show the progress on these three:

Health-Related MDGs

Most at risk for failure is MDG 5, maternal mortality. Of the 134 countries tracked, only 30 are on track to reach their goal by the end of 2015. The Lower Income Countries (LIC) are outpacing the Middle Income Countries (MIC) here, with 25% and 19% on track, respectively[2]. Maternal mortality is a complex issue, and progress may be slow because reducing it requires a multifactorial set of solutions that require changes made in multiple, disparate sectors; simply put, time may not be on our side. I’ve written previously about maternal mortality – see here and here for more.

Progress towards MDG 6, HIV/AIDs, is a bit better, but not much. Overall, 32 countries are on track, or 24% of the 134 countries. Once again, the LICs are dragging up the average, with 26% on track versus 21% for the MICs. This is a bit misleading because of the standard MDG 1990 baseline, as infection rates were rapidly increasing in the 1990s in sub-Saharan Africa; looked at from 2000 to 2010 alone, about three-fourths of the countries in sub-Saharan Africa would be on track versus the one fourth that are with the baseline scenario.

Finally, the brightest spot for health-related MDGs is MDG 4, child mortality; nearly half of the countries are on track, and fully 88% are at least partially on track. Here, the MICs are doing a bit better than LICs (52% to 46% on track).

Broadly speaking, the health MDGs fit the larger pattern of LIC-MIC convergence on MDG progress: “The gap between the progress of poor countries and MICs towards the MDGs continues to narrow. Poor countries’ average scores are now nearly identical to those of MICs (3.88 versus 3.96).” This is great news, as it means that LICs are being “transformed” into MICs from an output perspective; they’re outperforming what their GDP would’ve predicted a decade ago.

The report focuses heavily on financing from multilateral organizations (e.g., World Bank, International Monetary Fund) and national governments. In 2001, the governments of sub-Saharan Africa pledged to allocate 15% of their national budgets to health spending (referred to as the “Abuja Commitment”), which, for the majority of those countries, hasn’t happened; a few haven’t met even half that commitment. This appears to show up in the output measures: countries that are doing better on MDGs 4 and 5 generally have allocated more of their budgets to health spending.[3]

MDGs - Health Spending

So, with less than 1,000 days to go, where does that leave us with respect to the health-related MDGs? Unfortunately, we’ve heard the report’s answers before: spend more money and improve service delivery.  It’s the definition of boilerplate, except without any heat. The truth is that it’s extremely unlikely that MDGs 5 and 6 will be met, and MDG 4 is tenuous, too.

This shouldn’t stymie progress – there’s a lot that can be done in 1,000 days – but it’s important to be realistic. If we’ve learned nothing else, it’s that change on this scale takes a significant amount of time; maternal mortality, for example, seems to be a proxy for the health of the health system as a whole, and 15 years (from 2000 to 2015) may not be enough time to tease out the problems and implement the appropriate solutions.

It also shouldn’t obscure the fact that a lot of progress has been made. Hundreds of thousands of mothers are alive today that may not otherwise have been. Whatever the conceptual failings of the MDGs, they have focused the world community on very specific outcome measures; it’s no longer enough to discuss inputs alone. Results matter.

To recap: significant progress is being made on the health-related Millennium Development Goals, but it’s going to be tough to reach any of them by January 1st, 2016; reducing maternal mortality will be the most difficult, followed by reducing HIV/AIDs. 944 days and counting.

[1] This is myopic view of health, of course – all of the MDGs deal with health in a direct or indirect way: reducing extreme poverty and hunger, getting kids in school, having clean drinking water, and promoting gender equality all have significant health components and consequences.

[2] At first glance, this probably looks off – “The poorer countries are doing better than the less-poor countries?!” Remember, we’re looking at relative rates, not absolute rates; Egypt (a MIC) is competing with itself, not Uganda (a LIC), and because Egypt’s Maternal Mortality Ratio was lower to begin with, it may have a more difficult time reducing it by a further 75%.

[3] The usual caveat about correlation vs. causation applies here: this doesn’t prove that not allocating enough of the budget causes failing to meet the MDG. Perhaps countries that are more likely to follow through on their commitments are putting more non-monetary effort into reaching the MDGs, or perhaps the governments of those countries are stronger, etc., etc.