The Surprising Reason Why The World Is Getting Healthier




Reading news coverage tends to give one the impression that the world is perpetually on the brink of collapse. Yet it turns out we’re all getting much healthier — and we have democratic governance to thank.

Angus Deaton’s new book, The Great Escape, is a wonderful treatment of global inequality (I’m in the process of writing a full review). The book’s second and third chapters document two things conclusively: first, the developed world’s life expectancy has almost doubled in the past 150 years, and second, poorer countries have made huge progress in catching up since World War II.

What happened? One popular theory is economic growth. The Industrial Revolution made the First World richer, the theory goes, and then the rest started to quickly catch up after the emergence of the modern global economy.

Not so fast, Deaton says. Economic growth played some role in improving health, but it wasn’t the main cause. How do we know? “When we try to match the onset of economic growth with the improvements in health, the timing is wrong,” Deaton writes. “The improvements in child mortality across north-western Europe were much too uniform to be explained by economic growth, which began at different times in different countries.”

The same is true of the developing world in our time. Check out this chart Deaton put together comparing economic growth to decline in infant mortality, where each country is represented by a dot proportional to its population size (important largely because Indian and Chinese citizens make up a huge percentage of the improving-health contingent):


Notice any relationship between economic growth and fewer tragic deaths? Exactly. When you treat each country as a datapoint and look for overall trends, “there is no relationship [between growth and infant mortality] at all.” Indeed, Haiti, whose economy contracted from 1960 to 2009, showed a faster decline in infant mortality during that period than the growth behemoths, China and India.

What’s actually happening? Deaton gives the bulk of the credit to scientists and those most unsexy of heroes, politicians and public health officials. Scientific advancements, like the germ theory of disease, taught us what we needed to save lives — and then government did it. “The improvement of public health required action by public authorities,” Deaton writes, “which required political agitation and consent and could not have been accomplished through the market alone.”

Some concrete examples. Fixing the fecal-born illnesses that turned Industrial Revolution cities required big investments in sewage treatment infrastructure and public health monitoring. “Turning the germ theory into safe water and sanitation takes time and requires both money and state capacity,” Deaton says, and “these were not always available a century ago, and in many parts of the world they are not available today.”

He’s not wrong. The biggest killers in the developing world today — tuberculosis, malaria, diarrhea, and lower respiratory infections — are solved by “better pest control, better water, and better sanitation, all of which require collective action, organized by central or local governments.” They are, in short, “problems of public health, not private health care.”

The implications are far more wide-reaching than you might think. First, Deaton’s work suggests that the most pressing moral problem of our time — the horrific fates the world’s poorest suffer for the crime of being born in the wrong place — is actually two separate, albeit related, problems. Poverty and material deprivation make people’s lives immeasurably worse, but the things that tend to end these lives prematurely won’t be solved by turning the growth key. Better governance in and health assistance to poor countries are important things that are independent, to a significant degree, of economic development in those countries.

More deeply, the secret history of saving lives tells us that the health of citizens is always a government problem. Bill Gates and others like him do invaluable work, but nowhere in the world have the great victories over untimely death been won primarily by private forces. It’s just never happened.

This means that, in any society with publicly provided health infrastructure — which is to say, all of the successful ones — the state is intimately involved in ensuring its citizens lead healthy lives. The Obamacare-inspired debate in the United States about whether health care is a “right” the government ought to provide its citizens is thus misplaced; virtually everyone in the world already assumes the government is responsible for providing for the good health of its citizens.

It’s worth unpacking this point a bit. Health care, what Deaton calls the “physician-patient health care system,” isn’t the same thing as public health campaigns like vaccination or the distribution of malaria nets. But the basic philosophical argument for a state-enforced right to both is the same: the government has an obligation to do what’s necessary to preserve the health of its citizens against disease. It’s hard to see how, in principle, you could craft an argument for universal access to vaccination that wouldn’t necessarily imply a right to see a physician.

The point is buttressed by the practical reality of health care systems. Deaton looks at the private health care system in Rajasthan, India, where most doctors were “quacks of one kind or another,” some of whom “had not even graduated from high school.” The reason, he finds, is that the Rajasthani government lacks the ability to do the thing that states need to do to make health care reliable; it “is capable neither of delivering health care itself nor of providing the regulation, licensing, and policing that is required for an effective and safe private health care system.” Except in places like Rajasthan, the government is always-already involved in running the private health care system. There is no brightline between public health and private health care, because government involvement in both depends on the same basic premise: we deserve to be protected against preventable illness.

Of course, the fact that the government needs to play some role in the provision of health care isn’t an argument for Obamacare over catastrophic insurance and HSAs, or for single payer or a British-style nationalized health industry. It is, however, a nail in the coffin of the vulgar libertarian argument that we don’t have a right to health care. Anyone who thinks the massive reduction in death over the past 150 years is a good thing implicitly believes that we do. The real debate now is the right way to vindicate people’s right not to die.