The Great Escape Reflection

The Great Escape is Sir Angus Deaton’s story of how human civilizations have overcome and failed to overcome poverty over the past 250 years. As morbid as it sounds, I really enjoyed Deaton’s more recent book, Deaths of Despair (written with his wife Anne Case), so I had high hopes for this semi-classic work on development economics. However, because I consumed it as a free audiobook on Audible, I was not given access to the many charts described in this 12+ hour narrative. For this reason I am sure that I did not get as much out of the book as I could have. It is quite difficult, and perhaps not very safe to keep track of descriptions of charts and statistics in your head while driving a car. Nonetheless, I’m glad I gave it a shot because there were some very important high-level lessons and perspectives that I hope to recapitulate here.

Relative to today, for most of human history the population was small, economic growth was low, child and maternal mortality were high, and life-expectancy was low. Poverty was the default condition. Around the time of the Enlightenment (1685 - 1815), Western cultures began attempting to take their wellbeing into their own hands, as opposed to leaving it up to God. This led to some key scientific, agricultural, and medical discoveries that had enormous impacts on mortality and life expectancy. These included the germ theory of disease and vaccinations, which led to public health and sanitation improvements as well as the eradication of diseases like smallpox. 

These early advancements were a particular boon for childhood mortality, as children are very susceptible to infectious diseases in their first few years. Childhood mortality has a major influence on average life expectancy from birth, since deaths in early ages can pull the average down significantly. This implies that the increase in European life expectancy from around 35 in the 1700s to 65 in the 1950s was primarily driven by the decline in child mortality, as opposed to improvements in teenage or adult health. There is a saying in development economics that goes something like this: “as death ages, it moves from the bowels to the heart and lungs,” suggesting that when children avoid death early on from infectious diseases, they meet it later as adults in the form of chronic diseases like heart disease and cancer. 

In the decades following World War II (1950 - present), the West’s scientific ingenuity took up the battle against heart disease and made great progress there as well. One major factor was the recognition and acceptance that smoking causes heart disease and lung cancer. Deaton makes an interesting comment that we should not take for granted the priority of preventing a child’s death over that of an adult, because while a child would have more years to live, an adult has more connections in the community that would be lost. While I agree that we should not take this assumption for granted, I feel confident in saying that the former should be of greater importance. This is because a lost child also represents the lost potential connections to be made in their life, while an adult’s connections will inevitably be lost whether they pass now or in a few years.

So technological advancements were clearly of great importance for advancing human health and wellbeing. Indeed, Deaton cites this as the primary driver of the great escape. One of the beauties of these types of advancements is that in order for others to benefit from them, the knowledge merely needs to be shared, not rediscovered from scratch. Economic growth and development, Deaton’s second main driver of the great escape, is far less easily achieved or shared, and requires certain prerequisite conditions. He argues that rich countries providing aid to poor countries actually undermines the ability of poor countries to develop because it often allows their corrupt or ineffective governments to remain in power. 

Deaton primarily criticizes foreign aid that is given directly to these corrupt governments, which is understandable. He is less negative on GiveWell-style interventions, such as to programs that provide insecticide-treated bed nets and oral rehydration therapy, but he still seems to think that these are not the best ways to support developing countries. Instead, he argues that rich countries should either stay out of their business or invest in developing technologies like a vaccine for malaria that would greatly benefit these specific countries. As someone who has donated to these sorts of causes, this put me on the defensive, but to his credit it made me think deeper about this sort of giving. At the end of the day, I find it hard to believe that reducing child mortality or preventing people from going blind in a cost-effective manner could be net harmful for a country. And as Bill Gates mentions in a review of this book, Deaton leaves out countries who have successfully developed with the support of aid and seems to downplay the impact of global vaccine campaigns.

A good chunk of the book is dedicated to understanding inequality. As countries get richer, they tend to become more unequal. This is somewhat intuitive considering that when countries are poor, there isn’t enough wealth for great inequality to exist. Capitalism can obviously lead to inequality, but he also notes that technological advancement, particularly in the new digital age, makes it so there is a greater divide in earnings between those who are educated and have technical skills and those who don’t (this thread is picked up in Deaths of Despair). Globalization works to reduce global inequality by empowering the global poor, but increases inequality within countries like the U.S. who have their low-skilled labor sent abroad. Deaton notes that financial inequality can also lead to health inequality, as wealthier people can afford medical care and healthier life styles. His biggest concern with inequality is that in the US and other countries, capital can buy political influence, which enables and incentivizes capitalists to pursue rent seeking behavior. I completely agree with this sentiment - I can accept entrepreneurial people reaping financial rewards for their socially beneficial innovation, but they should not be given outsized political power.

There are many more interesting considerations from this book, such as the paradoxes and pitfalls of trying to measure health, wellbeing, inequality, and poverty over time and across individuals and societies. Unfortunately, I am not paid to write lengthy posts, so I will cut my reflection here. I would recommend this book to anyone interested in development economics or simply the modern history of health, wellbeing, and inequality. Deaton is an important critic of the traditional Effective Altruism approaches to improving global health and he has certainly made me more keen on the importance of strong institutions for creating a prosperous society.