Angus Deatons The Great Escape: Health, Wealth, and the Origins of Inequality is
a positive and optimistic assessment of worldwide well-being. Yet it is also a
sobering book because it identifies problems and vulnerabilities. It brings together
two important elements of well-being: health and prosperity. It is about the
endless dance between progress and inequality, about how progress creates inequality,
and how inequality can sometimes be helpful . . . and sometimes unhelpful
to progress (p. xiii).
The books perspective is global, though several chapters focus on the United
States. It is organized into three parts: Life and Death, Money, and Help. The
first two are self-explanatory; part 3 is mainly an argument that most foreign aid is
doing more harm than good.
In spite of the fact that the world is hugely unequal, life is better now than at
almost any time in history (p. 1), and the book is about the interplay between
progress and inequality. The global inequality of today is largely the creation of
modern economic growth. Health progress creates inequality in health just as economic
progress creates economic inequality.
Chapter 1 is a descriptive treatment of well-being in the world. Health and
wealth are strongly, though not perfectly, correlated among the worlds countries.
The relationship between income and life expectancy at birth is positive but nonlinear.
Life expectancy rises very steeply with income up to about $10,000 gross domestic
product (GDP) per capita (in price-adjusted 2005 U.S. dollars) and then flattens.
This is the epidemiological transition point at which the causes of most deaths shift
from infectious to chronic diseases.
Deaton is largely agnostic on the causality of income and health other than to
say that for nutrition people need money, and for sanitation governments need money.
He reports that proportional increases in income are associated with constant increases
in longevity. There is improvement over time in both health and income, but with
some catastrophic interruptions such as the Great Leap Forward in China from 1958
to 1961, which caused some 35 million deaths, and the HIV/AIDS epidemic.
The improvements in health are due to both income and practical knowledge,
and Deaton argues that knowledge is central and that income is a facilitator of other
aspects of well-being. He contends that although there is not a necessary connection
between economic growth and poverty reduction, in fact much of the reduced
poverty in the world is due to economic growth in the worlds two largest countries,
China and India.
The discovery and diffusion of the germ theory of disease were central to the
reduction of infectious disease and child mortality. This basic knowledge quickly
became available throughout the world, but implementing the knowledge was not
automatic. For example, preventing diseases now understood to be caused by waterborne
agents first required construction of safe water supplies. Turning the germ
theory into safe water and sanitation takes time and requires both money and state
capacity; these were not always available a century ago, and in many parts of the world
they are not available today (p. 97).
Deaton presents a challenge: Why should children in poor countries die when
they would not die if they were born in rich countries? Economic growth can bring
health improvements, but Deaton uses China to show that growth does not bring
any automatic improvement in the health component of wellbeing. In China, it was
policy that mattered: in effect, the authorities decided to trade off one aspect
of well-being for another (p. 116). In fact, he argues that there is no relationship
at all between the speed of growth and the speed of decline in infant mortality when
the data are analyzed by country (p. 118).
There is a good discussion of disagreements on how much health care is too
much. The trade-offs between health and other spending are usually not well understood
in the United States because many people do not realize that what their
employers pay for their insurance would otherwise come to them in wages. Deaton
calls for a process that allows the public to understand the ways in which income and
health interact and the ways that growth of health spending affects other aspects
Deaton documents the economic growth and rising standard of living in the
United States and their sources in appropriate institutions and practices. He shows
how these things make life better even though they dont make Americans proportionately
happier. He documents the slowdown in per capita growth in GDP and the
limitations of using GDP to measure well-being.
How does inequality arise? Deaton claims that it is the product of many different
mechanisms. One major source of inequality is the increasing demand for technological
skills. This kind of inequality is part of a system that is raising living standards for
everyone (p. 193). Deaton argues that even equality of opportunity does not assure
outcomes that are transparently just. . . . There is a deep conflict between incentives
and inequality, in families and in countries (p. 194).
Deaton is very concerned about rising inequality in the United States and
discusses its political sources and dynamicsfrom the minimum wage to the tax code to financial deregulation and the lobbying of Congress. The too big to fail promise
and the hundreds of millions in earnings that it allowed was [sic] a failure of government
regulation (pp. 21011).
The best news in this book is the globalization of prosperity since World War II.
Hundreds of millions of people have risen from poverty and destitution. Yet while
rich countries continue to grow and their average incomes to converge, the experience
of all the worlds countries is much more diverse. Several countries (China,
Hong Kong, Malaysia, Singapore, South Korea, Taiwan, Thailand, and Botswana)
have grown at more than 4 percent a year between 1960 and 2010, making for a
sevenfold increase in average incomes. But many countries have not grown at all, and
some (Central African Republic, Democratic Republic of the Congo, Guinea, Haiti,
Madagascar, Nicaragua, and Niger) are actually worse off than they were fifty years
ago. Yet because the worlds two largest countries are among the fast growers, the
average person in the world is better off than the average country (pp. 23435).
This is mainly good news (though it could obviously be even better), but we do
not really understand much about how it has happened. There is much that remains
mysterious about why some countries grow rapidly and some grow slowly (p. 237).
Deaton is rightly critical of efforts to advance our understanding by looking
at successes or failures and seeing what each has in common with the others.
The most controversial part of the book is surely the single chapter in part 3
titled How to Help Those Left Behind. The chapter explains the aid illusion
the erroneous belief that global poverty could be eliminated if only rich people
in rich countries were to give more money to poor people in poor countries
(pp. 26970). This hydraulic approach to aid is wrong. Fixing poverty is nothing
like fixing a broken car or pulling a drowning child out of a shallow pond (p. 274).
I find the chapter comprehensive, enlightening, and convincing. We are left with the
conclusion that both theory and experience suggest that economic growth is the
surest and most lasting solution to poverty (p. 281).
With Deatons help, we understand better how life expectancy and health
improved than how prosperity improved. As he indicates, knowledge is the key to
both, but the link between knowledge and improvements in public health is much
clearer than the link between knowledge and the economic growth that has made
much of the world better off.
Knowledge and ideas ranging from the germ theory of disease to the research
that linked smoking to lung cancer have observable links with health, and it is not
hard to know what to do to implement such knowledge and reap the health benefits.
Knowledge and ideas are also central to economic growth, but the causal pathways
are not nearly so clear, and, as Deaton acknowledges, we do not know enough about
how to make growth happen.
The Great Escape is a readable and fair-minded book. My complaints are
few and based largely on expectations that Deaton has raised with the wealth of
information he presents. I regret that a scholar of such knowledge and experiencedid not attempt more precise and comprehensive statements of the relationship
between progress and inequality in general or of the relationship between health
As Deaton says, the world has never been better than it is now (at least in terms
of life expectancy and material well-being). But we know more about how we got to
this situation with respect to longevity than we do with respect to prosperity. Both
advances may be fragile. The HIV/AIDS epidemic and the reemergence of polio and
tuberculosis show that change is not monotonic and that we must be on guard against
setbacks. But we understand less about how we got to the present advanced state
of world prosperity than we do about how infectious diseases were conquered. When
shocks such as the recent financial crisis and the Great Recession occur, we are less
well prepared to re-create the state of economic progress the world had achieved up
to that point.