Angus Deaton. The Great Escape: Health, Wealth, and the Origins of Inequality. Princeton: Princeton University Press. 2013.
Consider two passages. The first is a brutally succinct narrative of the moral shame of our time, global poverty: “Almost a billion people still live in material destitution, millions of children still die through the accident of where they are born, and wasting and stunting still disfigure the bodies of nearly half of India’s children.”
The second tells a rather more optimistic story: “Income and health have improved almost everywhere since World War II. There is not a single country in the world where infant or child mortality today is not lower than it was in 1950.”
That these are from the same book, Princeton economist Angus Deaton’s The Great Escape, is no doubt obvious given the subject of this review. But their juxtaposition reveals the core of Deaton’s argument: humanity’s greatest moral failure is also our greatest success story. The sheer scale of our world’s horror can boggle the mind, obscuring the realness of the suffering that suffuses the globe. The death of one a tragedy, a million a statistic, as the old saying (falsely attributed to Josef Stalin) goes.
And yet, despite our still shameful levels of indifference, we have succeeded in making millions of lives immeasurably better, gains that have largely come in the last 250 years.
The recognition that humanity has improved because we’ve collectively decided to improve it — that society works, essentially — is perhaps the most important of Deaton’s many insights. But there’s a hidden story in his book, which focuses principally on the ways in which advances in technology and economic systems have improved the world, about the moral progress we’ve made. We are, as a species, moving towards realizing our full potential for empathy. And this baseline truth should give us hope that the progress Deaton documents will continue. It is time to have faith.
Deaton’s academic work focuses on the measurement on poverty and health, and the bulk of the book is devoted to making that boring-sounding subject of general interest. It succeeds admirably: these numbers are the best tool we have for understanding humanity’s baseline condition, the things that determine when we die and if, before that time, we live well.
The Great Escape brims with numbers of this sort, measurements tracking the spread of “well-being” (loosely defined as health, wealth, and psychological satisfaction) throughout the world. Deaton has a series of clever ways for illustrating the basic point that things have gotten better. For instance, he tracks a middle class American woman’s life expectancy in time, finding that a baby born in 2010 would have nearly twice the expected lifespan of her grandmother. That’s how rapid some of the improvements are.
People around the world have shared in these gains. The escape from death started in Europe, where the “ideas of the Scientific Revolution and the Enlightenment eventually brought a revolution” in both lifespan and prosperity. Ideas like the germ theory of disease, sewage systems that separated feces from drinking water, and a host of other ailments made rapidly industrializing cities, previously cesspools, safe enough for humans to flourish. These ideas and subsequent ideas advanced rapidly in the West, leading to centuries of European economic and political dominance, but once developed, could not be contained. Post 1950, when developing countries began adopting Western innovations in earnest, the catchups in wealth and (particularly) health were dramatic.
However, every such advance opened up new inequalities. Around 1750, when the Enlightenment revolutions were just beginning, a member of a British ducal family’s life-expectancy was basically the same as that of a non-aristocrat. By the late 19th century, it was 20 years longer.
Likewise, massive uplift from poverty in India and China are the 20th century’s greatest victories — 573 million fewer people were living on a dollar a day in 2008 than 1980 because of Chinese growth alone. But these gains themselves have created new inequalities both inside India and China and between their wealthier populations and the poorest still stuck in slow-growth countries, particularly in Africa.
Deaton’s explanation for why progress and inequality are always twinned is one of the book’s most valuable contributions. Ideas and the new technologies they create don’t increase by magic. People are confronted with problems with the world and generate solutions to them, ideas which are then translated by governments and markets into real, life-saving solutions. Vaccines don’t distribute themselves.
But since politics and money are the two necessary ingredients for distributing wealth, the powerful and the wealthy tend to see those gains first. People with enough organized political clout will demand a working hygiene system before the less politically aware; wealthier countries will be able to afford expensive medical treatments before poorer ones.
So, Deaton explains, broad advancements in health and wealth occur in waves of inequality and catch-up. New ideas are developed, road-tested by the best-off, and then applied to the rest of society. This cycle explains how the world can be better off than it was, despite huge inequalities.
That’s not to say all inequalities are good, let alone “natural.” Tremendous inequality, Deaton argues, stymies progress: the reason economic growth in the West after 1750 kept on track, while the rest of the world fell behind, was in large part due to the elites in non-Western society. Growth happened “again and again” around the world, but “it was always snuffed out by powerful rulers or priests who either appropriated the innovations for themselves or banned the activity altogether because it threatened their own positions.” In a depressing chapter on the United States, Deaton suggests we may well be due for a repeat performance if the one percent can’t be reined in.
Better politics are the only solution. Deaton, aligning himself with Daron Acemoglu and James Robinson, argues that a country’s governing institutions are the keys to saving its citizens from disease and death. “Government capacity, a functioning legal and tax system, security of property rights, and traditions of trust” are what allow the healthy cycle of growth-driven inequality to triumph over its dangerous, elite-stagnated cousin. Democracy and rights check power’s propensity to corrupt these institutions; they give ordinary people an avenue to demand the fruits of growth that elites might prefer to consume alone.
Despite his (very persuasive) position of politics’ central role in saving the human race from misery, Deaton’s treatment of political development is curiously incomplete. The Great Escape‘s history of the innovations that have fueled improvements in health and wealth is painstaking, but the book performs no similar archaeology on the political ideas that allowed for the titular “Great Escapes” from illness and penury. If the West’s political advancements in the 1750s allowed it to make a break with the misery that characterized the past several thousand years of human civilization, then what produced them?
The answer is in The Great Escape, if you read between the lines. Deaton frequently credits the Enlightenment for Europe’s technological triumphs; the new rationalism taught that “happiness could be pursued by using reason to challenge accepted ways of doing things, including obedience to the crown and the church, and by finding ways of improving one’s life, including both material possessions and health.” But he never draws the obvious inference from that fundamentally moral advancement to the “political agitation and consent” that ensured that the poor and middle class would benefit from Europe’s boom.
This isn’t merely a matter of Deaton omitting the obvious, namely that Enlightenment political ideals transformed European and ultimately global politics. Rather, it suggests that there’s a third type of innovation, beyond those of science and business, that propels humanity forward: moral advancement. Enlightenment politics were, after all, a product of Enlightenment morality. The unanswerable moral challenge to monarchic privilege — “Who are you to rule us? Why are we not your equals?” — inspired the democratic, rights-respecting political systems that underpinned Deaton’s escapes.
So morality is perhaps best thought of as a third kind of technology. Much like innovations benefiting public health and the economy, moral innovations spread unequally, beginning in the places where they be easily taught and taking root in fertile political climates. The American and French Revolutions were caused by political conflict, not by people reading Locke and Rousseau — but the fact that they had read those thinkers helped ensure that the institutions that followed would be liberal (though the effect was just a tad delayed in France).
Once invented, moral advancements can’t be contained inside national borders — another similarity between them and Deaton’s technologies. A belief in the fundamental moral equality of persons and the attendant democratic institutions has spread globally. Democracy is the world’s dominant form of government and belief in human rights is increasingly transcending national borders.
Which is why the end of Deaton’s book is so curious. The last chapter, much shorter than the prior two and a jarring tonal shift from what come before, is a polemic against foreign aid. The Great Escape pillories virtually all of it, caveating health assistance explicitly and, one would hope, disaster aid. This is by far the book’s most controversial chapter, and it’s been widely criticized for oversimplifying a high complex and technical debate. That being said, Deaton’s critique is important corrective to the simple triumphalism of a Jeffrey Sachs or Peter Singer. His criticisms are worth taking seriously.
But his harsh critique of aid policy misses the most important thing about foreign aid: that it exists at all. Deaton notes that foreign aid is “something completely different” from any transfer of wealth between countries beforehand, as virtually all others were the rich taking from the poor, but he fails to draw out the clear implication: we’re getting another upgrade in our moral technologies.
Foreign aid is a first tentative step towards last frontier of Enlightenment morality: that all persons, regardless of national origin, are created equal. The idea that government policy shouldn’t discriminate on the basis of race, gender, and (increasingly) sexual orientation is fairly mainstream, but the idea that governments owe the same consideration to foreign citizens that they give their own is still astonishingly novel. Can you imagine any President of the United States suggesting that the rights of foreigners could trump America’s “national interest?”
Aid is a challenge to this old nationalism. Recognizing that we owe assistance to alleviate the burden of poverty and disease is a tentative step towards accepting what contemporary moral philosophers call “global justice;” the idea that the ideals of political justice that we previously believed to apply only inside state boundaries actually hold across them. It’s not just inequality between Main Street and Wall Street that should matter in Washington, but also inequality between Main Street, Pittsburgh and Main Street, Kinshasa.
Deaton, immersed in a world of moral philosophers and development professionals, seems not to appreciate just how radical a development this is. “The ethical arguments for the duty to assist are surely overwhelming,” he says, dismissing the idea that rich societies fail to help the poor out of simple moral indifference as too monstrous to imagine. Yet, as Bill Gates points out in a recent Wired essay, it’s obvious that “the world acts as though some lives aren’t worth as much as others.” Deaton himself acknowledges that “the case for assistance to fight disease such as HIV/AIDS or smallpox is strong” and that the global community could invest significantly greater sums in efforts to find better treatments for these ailments. Why don’t we?
It’s the same reason Americans don’t want to tear down restrictions on legal immigration or send U.S. troops to serve under U.N. command in peacekeeping operations: Americans, like most people nowadays, think of the lives and welfare of their co-nationals as more important than that of someone from China or the Central African Republic. The yawning gap between current policy in wealthy countries and policies that would maximally benefit those in abject suffering around the world makes this point blindingly clear.
But there’s reason to hope. That prominent thinkers like Deaton are debating, not whether we need to help the poor, but how best to do it, suggests that the belief in global justice is becoming more mainstream. As does the proliferation of international institutions: courts, development agencies, economic bodies, treaties, and, most importantly, the United Nations itself. These organizations have developed for their own reasons, but they share a baseline assumption that governments are obligated to contribute to global, and not just national, interests. That such organizations have grown more, not less, relevant as time has gone on suggests their power is growing.
That these developments are logical extensions of the same ideas about equality that underpinned the last 200 years of human progress Deaton so ably documents should give us hope about the next two centuries. If we really do improve our moral technology, and people start taking the idea of global justice as seriously as they take the promises of democracy, then the next Great Escape may depend on institutions as unimaginable to us as our world would have been in 1750.