Book review: Plagues and the Paradox of Progress

When we went into lockdown earlier this year, I quickly gathered together some books from my office, not knowing how long it would be before I could return. One of those books was Plagues and the Paradox of Progress by Thomas Bollyky. It seemed quite relevant (perhaps too relevant) at the time, but I've only just gotten finished with reading it now.

The premise of the book is relatively simple. High-income countries took a long time to tackle their own problems of infectious disease (like cholera, typhoid, etc.), and in the process of tackling infectious diseases, those countries developed the types of institutions (like health systems) that have contributed to high income countries' ongoing success. In contrast, modern-day low-income countries haven't had to go through the same long process of institution building in order to combat infectious diseases, as they have been able to import the solutions from high income countries, often with the support of international aid or philanthropic donors. So, while infectious disease no longer kills millions of people in low income countries, the lack of effective institutions keeps those countries poor - that is what Bollyky terms the paradox of progress. As Bollyky summarises:

...the world has gotten better in ways that should make us worry. The last two decades have brought dramatic reductions in endemic infectious disease and child mortality, but not the improvements in health-care systems, responsive governance, and employment opportunities that accompanied these changes in wealthier nations in the past. 

On the face of it, it's a compelling narrative, supported by what is among the most extensively researched evidence base I've seen in a book (for instance, Chapter 4 is 34 pages, but has 180 endnotes of references). However, the narrative is not entirely convincing, because it lacks strong causal evidence. It is all very well to present lots of evidence of how bad infectious diseases were in the past, and describe how high income countries dealt with them, but quite another to export that experience to low income countries. If you're not able to first establish the causal links, then your evidence base is at best partial. This is one of the problems that the Kuznets Curve faces - it looks good based on the experience of high income countries, but falls apart when exposed to data from low income countries.

I feel like the book also dramatically oversimplifies the issues. The role of institutions in economic development involves a huge literature, on which Bollyky barely touches the surface. To some extent, that's because that literature would broaden the scope of the book to an unmanageable extent. However, it also leaves the book without a clear relationship to a pretty important section of the literature.

It also leads to a policy prescription in the concluding chapter that can best be described as banal. I think almost anyone could have recommended secure property rights over land, and increased investment in education and primary health care, as important policy goals for low income countries, regardless of any link to infectious disease. And the links between those recommendations that the evidence in the preceding chapters is pretty tenuous, especially in the case of property rights.

Aside from those major gripes, the book is wonderfully well written and easy to read. And as I said, it is incredibly well sourced, so an interested reader can easily follow up on any of the evidence that Bollyky presents. The book also had some prescient moments that call to mind the current pandemic crisis:

Several years after the Ebola outbreak, coordination and funding of international epidemic and pandemic preparedness and response remain ad hoc and dependent on media attention. "We still are not ready for the big one," said Ron Klain, the former US Ebola czar, to the Washington Post in October 2017.

Indeed. Also this:

The United States was (and remains) woefully ill-prepared for the threat of antibiotic resistance and future pandemics.

As Americans have been discovering this year, to the dismay of many. However, Bollyky does make some clear errors, one of which is among my pet peeves - comparing stocks with flows:

The market capitalization of Philip Morris International at $187 billion (as of July 2017) is larger in nominal terms than the economies of most of the 180 countries where that company sells Marlboro and its other brands of cigarettes.

It may be technically true, but it's a worthless comparison, because a market capitalisation is a stock (based on fundamentals, it would be the present value of all future cash flows of the corporation), while GDP is an annual flow.

Overall, while the book was an enjoyable read, I don't feel like I learned much from it, and it certainly falls short of providing a convincing argument to me.