Over the past two centuries, the world has become much richer and its population has improved in health. But this historic break should not mask the great inequalities in access to development between countries, reminds us Nobel Prize winner in economics Angus Deaton.
What is development? We know that an exploration of the concept cannot reduce it to its material dimension alone: alongside wealth or income, we must also consider health, education, happiness, etc., to take its measure. In The Great EscapeAngus Deaton takes stock of the progress made since the start of the 19e century according to two dimensions, the health and wealth of populations. The joint study of these two aspects considerably enriches the usual analysis of development.
Wealth often goes hand in hand with other dimensions of development: the richest countries are also those whose inhabitants most often report having a satisfying life, a correlation that extends to other dimensions of development. If there is a correlation, is there a more formal, deeper link than simply statistical? The answer to this question leads to different public policies.
For Angus Deaton, some low-cost policies could improve the lives of many people more effectively than development aid in its current form. For some health services, a vertical logic must still prevail: it is more efficient to centralize certain policies in the hands of international experts, such as the immunization program of theUNICEF or oral rehydration therapies. However, he concludes that it is the improvement of health regulation and policies in developing countries that will have the greatest impact.
A healthier, richer, and still unequal world
For a book that is aimed at a wide audience, The Great Escape achieves a first tour de force, that of mobilizing numerous statistical and graphic indicators, without them ever being indigestible. Two observations are worth its title to the work: the persistent improvement in the material condition of many human beings, and the considerable lengthening of their life expectancy.
In Western countries, life expectancy at birth increased by 30 years during the 20e century. This progress reflects first the diffusion of the microbial theory, which allowed a reduction in infant mortality thanks to progress in the treatment of infectious diseases, whooping cough, diphtheria, poliomyelitis, measles, tetanus, etc. The improvement continued thanks to progress in the treatment of chronic diseases, which affect older people, cardiovascular diseases and cancer. Today, there is no inflection in the increase in life expectancy in developed countries: it is difficult to know if this progress will ever stop.
During the international epidemiological transition, in the middle of the 20e century, the progress made in rich countries has been transferred to developing countries. Thus, life expectancy at birth has since increased by 25 years, despite the dramatic setback linked to the epidemic of AIDS. Penicillin, sulfonamides, vaccination campaigns and oral rehydration therapies have played a major role. The level of wealth of these countries has no determining impact. To continue the progress that has been made, it seems that the two policies that would have the greatest impact on health in developing countries at the lowest cost today are hygiene education and the capacity of the State to organize a health policy.
Similarly, developed countries have seen the material well-being of their inhabitants progress, and converge (on average), over the same period. GDP per capita (a questionable indicator criticized in the book) in the United States in 2012 is 5 times that of 1929. Income inequalities, for their part, stand out much more than health inequalities. Since the end of the 1970s, the average income of the richest 5% of Americans has doubled, while that of the poorest 20% has stagnated. What are the reasons for this divergence? Among the few explanations that he examines, Angus Deaton distinguishes the role of finance in the concentration of income, and questions the compatibility of such inequalities with the functioning of a democracy.
It is more difficult to compare the income of people in poor countries because of their different consumption habits; it is also difficult to define a poverty line independently of political considerations, and a fortiori to compare countries using this criterion. However, we know that in some countries, such as the Central African Republic, the Democratic Republic of Congo, Guinea, Haiti, Madagascar, Nicaragua and Niger, average income has fallen over the last 50 years. Overall, inequalities have increased between countries. During the same period, China, Hong Kong, Malaysia, Singapore, South Korea, Taiwan and Botswana have multiplied their average income by 7. The growth of very large countries – India and China – allows the balance sheet to show a slight decrease in inequalities between all human beings.
The link between health and wealth
The first chapter opens with the graph of the “Preston curve”, which shows the link between life expectancy and average income in each country. The link between life expectancy and wealth can have three different explanations. Does wealth promote better health? Do health and wealth have common determinants? Does better health promote economic activity? The economist’s job is largely to identify which causal relationships, which explanations, are the right ones. Second tour de force of The Great EscapeAngus Deaton demonstrates that this identification work can be made affordable and accessible. He focuses on the first two mechanisms.
Does wealth promote better health? The author answers in the affirmative, but he denies that this mechanism is the most useful for understanding the comparative trajectory of countries. Certainly industrial progress has generated its own discoveries in the field of health, such as penicillin and sulfonamides. It has also encouraged discoveries in other fields, notably because urbanization has favored research against epidemic diseases. It is to this mechanism that the book attributes in particular the discovery of the microbial theory. However, Angus Deaton points out that treatments that could save many lives in developing countries are in reality inexpensive, and yet they are not mobilized. He also shows that the AIDS has affected several African countries, regardless of their relative wealth. At the very least, wealth is therefore not enough to explain the relative gaps between countries in terms of health, any more than it is to explain the relative gaps within each country.
What determinants do health and wealth have in common? The book emphasizes the role of institutions. Vertical approaches, such as the vaccination programs of theUNICEFof theWHO or of GAVI Alliance, implemented from rich countries, have helped to resolve several global epidemics. In other cases, however, they cannot replace a national health policy that alone would be able to promote public hygiene. The book gives the example of the fight against the epidemic of AIDSwhich requires the local involvement of clinics and health personnel. Similarly, national and local institutions play a key role in the dynamics of growth, or more often in its inhibition. This is true of kleptocratic regimes, such as the Democratic Republic of Congo under Mobutu Sese Seko or Ethiopia under Meles Zenawi Asres, which are enriching themselves at the expense of the health and economic activity of their population. It is also true of the United States, where only the richest have become richer over the past 40 years.
What to do?
The last chapter of the book compares the merits of several solutions. He uncompromisingly criticizes development aid, which he believes is responsible for more harm than progress, and more generally, the interference of rich countries in the affairs of developing countries. The conflicts of interest in which donors are caught doom their action to failure, even when it comes from good intentions. On the recipient side, foreign aid has a crowding-out effect on other resources that can be mobilized for development, and supports questionable regimes. The effect of development aid on economic growth has proven notoriously difficult to measure. Faced with this failure, development aid has largely focused on the objective of reducing poverty, in particular through the Millennium Development Goals, then the Sustainable Development Goals. However, as the author’s analysis shows, reducing poverty is not enough to deal with certain epidemics, which are the responsibility of public health policies.
Conversely, supporting the building of local state capacity and improving the international environment could finally enable the poorest populations to also escape poverty and disease. Here are the avenues that Angus Deaton finds most promising:
– Even in contexts of low institutional development, it remains possible to treat water and encourage public hygiene, at low cost.
– Guaranteeing pharmaceutical companies a market for their products would encourage them to focus on solving epidemics that mainly affect poor countries. For example, several donors, under the umbrella of the Gavi organization, have committed to buying a vaccine to fight pneumococcal infections. This guaranteed market mechanism has allowed vaccines to be distributed much more quickly to 50 poor countries.
– Agricultural protectionism in rich countries reduces the income of agricultural producers in developing countries and increases the price paid by consumers. The author calls for its global elimination.
– Finally, trade, finance, and international treaties must systematically isolate kleptocratic regimes (even if it means not helping the populations concerned), and encourage progress in health administrations in fragile states.
Like Angus Deaton’s academic work, this book is discreetly luminous. It shows that health policies implemented in developing countries are sometimes ineffective, because they are based on an incomplete analysis. It considerably enriches the diagnosis by considering health and wealth issues together. The result is a demanding book, which offers concrete, immediately achievable solutions, but which are difficult to reduce to one or two simple messages.