Thomas J.Bollyky, Plagues and the Paradox of Progress: Why the World is Getting Healthier in Worrisome Ways. Cambridge, MA: The MIT Press. 280 p. $27.95.

Abstract

Currently, Niger's GDP per capita is $393; in 1980 it was $419. Today, students in Niger average 5 years of schooling, the lowest in the world, and just $71 is spent on the average Nigerien's health each year. The government is weak and corrupt, the country has the world's second lowest Human Development Index, and it is surrounded by regions experiencing violent insurgences. Yet, compared to 25 years ago, its life expectancy of 61 is 14 years higher and its infant mortality rate more than 60 percent lower. Over the past decade, the death rate from HIV/AIDS has dropped over 60 percent, malnutrition by 35 percent, malaria by 27 percent, and diarrheal disease by 48 percent. Bollyky, the Director of Global Health at the Council of Foreign Relations, uses Niger's statistics to illustrate that control over infectious disease and child mortality no longer depends on state capacity or income level, factors that were central to the control of infectious disease in now developed countries. This disconnect, while a notable accomplishment, worries Bollyky. Millions of infants and children, that formerly would have died, have survived as global vaccination campaigns have virtually eradicated smallpox and measles. The global distribution of mosquito netting and oral rehydration kits has significantly reduced the incidence of malaria and diarrheal diseases. These survivors have matured, and many now find themselves living impoverished lives in countries with underdeveloped health care systems that lack the capability to deal with unprecedented increases in noncommunicable diseases. They flee, in large numbers, to rapidly growing cities with poor infrastructures and few productive jobs. For Bollyky, whether the recent remarkable control of infectious disease will end with tragedy or triumph is yet to be determined. Bollyky argues his case using historical and disease-specific narratives. Chapter 1 covers the history of infectious disease from premodern time, when more advanced countries tended to be more disease-ridden, to the modern era when wealth and public health advances reversed that relationship. Chapter 2 traces the 1950s smallpox and malaria eradication campaigns to their colonial and military roots, noting that these top-down technology-driven strategies, while producing dramatic results, required few fundamental changes in governments or economies. Chapter 3 looks at the recent control of childhood disease; effective vaccines for measles, mumps, and rubella were only developed in the 1960s. The ensuing dramatic declines in childhood diseases occurred very quickly and produced age structures with distinct “youth bulges.” Bollyky contrasts the success that China has had in securing its demographic dividend with Kenya's much more limited success. Chapter 4 examines the story of tuberculosis, cholera, and other intestinal diseases, ones that in the past had made cities dangerous places in which to live. These diseases can now be “frugally” controlled, but the result has been the explosive growth of “poor world cities,” such as Dhaka, where population growth has outpaced gains in access to clean water, adequate sanitation, and schools. Chapter 5 assesses the very recent international health campaigns that have targeted the diseases common to the world's poorest and most ecologically challenged countries: meningitis and other neglected infectious and parasitic diseases. Success here has produced growing cohorts of young adults for whom emigration seems to hold the only key to a positive future. Today less than 20 percent of the total death and disability in South Asia is caused by infectious diseases, and it is less than 44 percent in sub-Saharan Africa. By 2040, Bangladesh's health burden will look like that of the contemporary United States, dominated by cancer, heart disease, and other noncommunicable diseases. Bollyky contends that what will be needed to deal with this new health burden is much more than just a revamped health care system. What will be needed is freer trade, more rapid economic growth, a more inclusive educational system, and better governance.