CHAPTER 6

HEALTH

How do we explain the gift of life that has been granted to more and more of our species since the end of the 18th century? The timing offers a clue. In The Great Escape, Deaton writes, “Ever since people rebelled against authority in the Enlightenment, and set about using the force of reason to make their lives better, they have found a way to do so, and there is little doubt that they will continue to win victories against the forces of death.”¹ The gains in longevity celebrated in the previous chapter are the spoils of victory against several of those forces—disease, starvation, war, homicide, accidents—and in this chapter and subsequent ones I will tell the story of each.

For most of human history, the strongest force of death was infectious disease, the nasty feature of evolution in which small, rapidly reproducing organisms make their living at our expense and hitch a ride from body to body in bugs, worms, and bodily effluvia. Epidemics killed by the millions, wiping out entire civilizations, and visited sudden misery on local populations. To take just one example, yellow fever, a viral disease transmitted by mosquitoes, was so named because its victims turned that color before dying in agony. According to an account of an 1878 Memphis epidemic, the sick had “crawled into holes twisted out of shape, their bodies discovered later only by the stench of their decaying flesh. . . . [A mother was found dead] with her body sprawled across the bed . . . black vomit like coffee grounds spattered all over . . . the children rolling on the floor, groaning.”²

The rich were not spared: in 1836, the wealthiest man in the world, Nathan Meyer Rothschild, died of an infected abscess. Nor the powerful: various British monarchs were cut down by dysentery, smallpox, pneumonia, typhoid, tuberculosis, and malaria. American presidents, too, were vulnerable: William Henry Harrison fell ill shortly after his inauguration in 1841 and died of septic shock thirty-one days later, and James Polk succumbed to cholera three months after leaving office in 1849. As recently as 1924, the sixteen-year-old son of a sitting president, Calvin Coolidge Jr., died of an infected blister he got while playing tennis.

Ever-creative Homo sapiens had long fought back against disease with quackery such as prayer, sacrifice, bloodletting, cupping, toxic metals, homeopathy, and squeezing a hen to death against an infected body part. But starting in the late 18th century with the invention of vaccination, and accelerating in the 19th with acceptance of the germ theory of disease, the tide of battle began to turn. Handwashing, midwifery, mosquito control, and especially the protection of drinking water by public sewerage and chlorinated tap water would come to save billions of lives. Before the 20th century, cities were piled high in excrement, their rivers and lakes viscous with waste, and their residents drinking and washing their clothes in putrid brown liquid.³ Epidemics were blamed on miasmas—foul-smelling air—until John Snow (1813–1858), the first epidemiologist, determined that cholera-stricken Londoners got their water from an intake pipe that was downstream from an outflow of sewage. Doctors themselves used to be a major health hazard as they went from autopsy to examining room in black coats encrusted with dried blood and pus, probed their patients’ wounds with unwashed hands, and sewed them up with sutures they kept in their buttonholes, until Ignaz Semmelweis (1818–1865) and Joseph Lister (1827–1912) got them to sterilize their hands and equipment. Antisepsis, anesthesia, and blood transfusions allowed surgery to cure rather than torture and mutilate, and antibiotics, antitoxins, and countless other medical advances further beat back the assault of pestilence.

The sin of ingratitude may not have made the Top Seven, but according to Dante it consigns the sinners to the ninth circle of Hell, and that’s where post-1960s intellectual culture may find itself because of its amnesia for the conquerors of disease. It wasn’t always that way. When I was a boy, a popular literary genre for children was the heroic biography of a medical pioneer such as Edward Jenner, Louis Pasteur, Joseph Lister, Frederick Banting, Charles Best, William Osler, or Alexander Fleming. On April 12, 1955, a team of scientists announced that Jonas Salk’s vaccine against polio—the disease that had killed thousands a year, paralyzed Franklin Roosevelt, and sent many children into iron lungs—was proven safe. According to Richard Carter’s history of the discovery, on that day “people observed moments of silence, rang bells, honked horns, blew factory whistles, fired salutes, . . . took the rest of the day off, closed their schools or convoked fervid assemblies therein, drank toasts, hugged children, attended church, smiled at strangers, and forgave enemies.”⁴ The city of New York offered to honor Salk with a ticker-tape parade, which he politely declined.

And how much thought have you given lately to Karl Landsteiner? Karl who? He only saved a billion lives by his discovery of blood groups. Or how about these other heroes?

The researchers who assembled these conservative estimates calculate that more than five billion lives have been saved (so far) by the hundred or so scientists they selected.⁵ Of course hero stories don’t do justice to the way science is really done. Scientists stand on the shoulders of giants, collaborate in teams, toil in obscurity, and aggregate ideas across worldwide webs. But whether it’s the scientists or the science that is ignored, the neglect of the discoveries that transformed life for the better is an indictment of our appreciation of the modern human condition.

As a psycholinguist who once wrote an entire book on the past tense, I can single out my favorite example in the history of the English language.⁶ It comes from the first sentence of a Wikipedia entry:

Smallpox was an infectious disease caused by either of two virus variants, Variola major and Variola minor.

Yes, “smallpox was.” The disease that got its name from the painful pustules that cover the victim’s skin, mouth, and eyes and that killed more than 300 million people in the 20th century has ceased to exist. (The last case was diagnosed in Somalia in 1977.) For this astounding moral triumph we can thank, among others, Edward Jenner, who discovered vaccination in 1796, the World Health Organization, which in 1959 set the audacious goal of eradicating the disease, and William Foege, who figured out that vaccinating small but strategically chosen portions of the vulnerable populations would do the job. In Getting Better, the economist Charles Kenny comments:

The total cost of the program over those ten years . . . was in the region of $312 million—perhaps 32 cents per person in infected countries. The eradication program cost about the same as producing five recent Hollywood blockbusters, or the wing of a B-2 bomber, or a little under one-tenth the cost of Boston’s recent road-improvement project nicknamed the Big Dig. However much one admires the improved views of the Boston waterfront, the lines of the stealth bomber, or the acting skills of Keira Knightley in Pirates of the Caribbean, or indeed of the gorilla in King Kong, this still seems like a very good deal.⁷

Even as a resident of the Boston waterfront, I’d have to agree. But this stupendous achievement was only the beginning. Wikipedia’s definition of rinderpest (cattle plague), which starved millions of farmers and herders throughout history by wiping out their livestock, is also in the past tense. And four other sources of misery in the developing world are slated for eradication. Jonas Salk did not live to see the Global Polio Eradication Initiative approach its goal: by 2016 the disease had been beaten back to just thirty-seven cases in three countries (Afghanistan, Pakistan, and Nigeria), the lowest in history, with an even lower rate thus far in 2017.⁸ Guinea worm is a three-foot-long parasite that worms its way into the victim’s lower limbs and diabolically forms a painful blister. When the sufferer soaks his or her foot for relief, the blister bursts, releasing thousands of larvae into the water, which other people drink, continuing the cycle. The only treatment consists of pulling the worm out over several days or weeks. But thanks to a three-decade campaign of education and water treatment by the Carter Center, the number of cases fell from 3.5 million in twenty-one countries in 1986 to just twenty-five cases in three countries in 2016 (and just three in one country in the first quarter of 2017).⁹ Elephantiasis, river blindness, and blinding trachoma, whose symptoms are as bad as they sound, may also be defined in the past tense by 2030, and measles, rubella, yaws, sleeping sickness, and hookworm are in epidemiologists’ sights as well.¹⁰ (Will any of these triumphs be heralded with moments of silence, ringing bells, honking horns, people smiling at strangers and forgiving their enemies?)

Even diseases that are not obliterated are being decimated. Between 2000 and 2015, the number of deaths from malaria (which in the past killed half the people who had ever lived) fell by 60 percent. The World Health Organization has adopted a plan to reduce the rate by another 90 percent by 2030, and to eliminate it from thirty-five of the ninety-seven countries in which it is endemic today (just as it was eliminated from the United States, where it had been endemic until 1951).¹¹ The Bill & Melinda Gates Foundation has adopted the goal of eradicating it altogether.¹² As we saw in chapter 5, in the 1990s HIV/AIDS in Africa was a setback for humanity’s progress in lengthening life spans. But the tide turned in the next decade, and the global death rate for children was cut in half, emboldening the UN to agree in 2016 to a plan to end the AIDS epidemic (though not necessarily to eradicate the virus) by 2030.¹³ Figure 6-1 shows that between 2000 and 2013 the world also saw massive reductions in the number of children dying from the five most lethal infectious diseases. In all, the control of infectious disease since 1990 has saved the lives of more than a hundred million children.¹⁴

Figure 6-1: Childhood deaths from infectious disease, 2000–2013

Source: Child Health Epidemiology Reference Group of the World Health Organization, Liu et al. 2014, supplementary appendix.

And in the most ambitious plan of all, a team of global health experts led by the economists Dean Jamison and Lawrence Summers have laid out a roadmap for “a grand convergence in global health” by 2035, when infectious, maternal, and child deaths everywhere in the world could be reduced to the levels found in the healthiest middle-income countries today.¹⁵

As impressive as the conquest of infectious disease in Europe and America was, the ongoing progress among the global poor is even more astonishing. Part of the explanation lies in economic development (chapter 8), because a richer world is a healthier world. Part lies in the expanding circle of sympathy, which inspired global leaders such as Bill Gates, Jimmy Carter, and Bill Clinton to make their legacy the health of the poor in distant continents rather than glittering buildings close to home. George W. Bush, for his part, has been praised by even his harshest critics for his policy on African AIDS relief, which saved millions of lives.

But the most powerful contributor was science. “It is knowledge that is the key,” Deaton argues. “Income—although important both in and of itself and as a component of wellbeing . . .—is not the ultimate cause of wellbeing.”¹⁶ The fruits of science are not just high-tech pharmaceuticals such as vaccines, antibiotics, antiretrovirals, and deworming pills. They also comprise ideas—ideas that may be cheap to implement and obvious in retrospect, but which save millions of lives. Examples include boiling, filtering, or adding bleach to water; washing hands; giving iodine supplements to pregnant women; breast-feeding and cuddling infants; defecating in latrines rather than in fields, streets, and waterways; protecting sleeping children with insecticide-impregnated bed nets; and treating diarrhea with a solution of salt and sugar in clean water. Conversely, progress can be reversed by bad ideas, such as the conspiracy theory spread by the Taliban and Boko Haram that vaccines sterilize Muslim girls, or the one spread by affluent American activists that vaccines cause autism. Deaton notes that even the idea that lies at the core of the Enlightenment—knowledge can make us better off—may come as a revelation in the parts of the world where people are resigned to their poor health, never dreaming that changes to their institutions and norms could improve it.¹⁷