Time of Indifference

During the cholera epidemic of 1849, Henry Mayhew, the great observer of London life, visited the district of Bermondsey south of the Thames. He wrote that the river water the residents drank and bathed in

appeared the colour of strong green tea, and positively looked as solid as black marble in the shadow—indeed it was more like watery mud than muddy water…. As we gazed in horror at it, we saw drains and sewers emptying their filthy contents into it; we saw a whole tier of doorless privies in the open road, common to men and women, built over it; we heard bucket after bucket of filth splash into it, and the limbs of the vagrant boys bathing in it seemed by pure force of contrast, white as Parian marble.

Mayhew visits a house where an infant has died of cholera and is told that its inhabitants really do drink the water. He asks whether they have tried to get their landlord to do something about it, and is told, “‘Yes, sir, and he says he will do it, and do it, but we know him better than to believe him.'”¹

Bermondsey is now a middle-income London neighborhood, but its death rate is still nearly the highest in the city.² Like all British people, its residents have access to reasonably good health care through the National Health Service, so why are they so unhealthy? Today people in Bermondsey die not from cholera and scarlet fever, but mainly from diseases of adulthood that are not considered contagious, such as heart disease, stroke, diabetes, and cancer of the stomach and lung. Lung cancer is known to be caused by smoking, but a number of researchers have proposed that the seeds of certain other diseases of middle and old age are actually planted in childhood, or even before. As George Davey Smith, David Gunnell, and Yoav Ben-Shlomo explain in Poverty, Inequality, and Health, poverty in childhood, and even among parents and grandparents, may predispose people today to many chronic adult diseases.³ So even though no one who lived in Bermondsey during the nineteenth-century cholera epidemics survives today, the poverty and infirmity of those times haunt their descendants like a kind of genius loci.

Many common illnesses in high-income countries today may be legacies of the Industrial Revolution, a particularly unhealthy historical period. By the middle of the nineteenth century, people in the Western world were becoming, on average, slightly shorter in height. By 1900, Europeans and Americans were growing again, and since then each generation has been taller than the one before it. But between around 1820 and 1870, physical growth in the West stalled, and at the same time, rates of death and illness increased.⁴ The Industrial Revolution, which brought prosperity to many people, also brought crowding, poverty, malnutrition, and disease to many more.

Today, new technology and expanded markets for commodities and labor are creating new economic and social changes, and just as in the nineteenth century, there are reasons to worry about the effects of the new economy on human welfare. Everywhere the health of the middle class is improving, but in many parts of the world, the health of the poor is not keeping pace. Especially in countries where AIDS, tuberculosis, and malaria are common, the gap between the health of people in rich and poor nations, and the gap between the health of the rich and poor within nations, are widening. The average Japanese person lives about twice as long as the average person in Malawi, Sierra Leone, or Uganda. Infant mortality in Africa may be five or ten times as high as it is in the West. In the United States, the life expectancy of Native Americans living on certain reservations lags by decades behind that of well-to-do suburban whites.

As the editors of Challenging Inequities in Health write, there is a growing feeling that such enormous inequalities, while hardly new, are unacceptable, because they so often result from such social injustices as poor access to health care, inadequate food, impure water and air, unsafe working conditions, and extreme poverty. The physical suffering of the poor is not only abhorrent in its own right, but also serves as a barometer of the fairness of the underlying social order. Several new books provide a general view of health and poverty in the world today, and speculate that something is ailing the planet at large.

1.

Betrayal of Trust: The Collapse of Global Public Health, by the Newsday reporter Laurie Garrett, argues that health systems everywhere, but particularly those that serve the poor, are under increasing strain. Garrett describes health disasters in four countries during the 1990s, including an outbreak of pneumonic plague in Surat, India, and an Ebola virus outbreak in Kikwit, Zaire (now the Democratic Republic of the Congo). In the former Soviet Union, a health crisis has led to a steep decline in life expectancy since 1990. In the United States, despite enormous sums spent on medical care, nearly forty million people lack health insurance, and many health problems pose growing threats, including drug resistant bacterial infections, food poisoning, and AIDS.

Garrett is a brave journalist, the Kate Adie or Christiane Amanpour of the germ world, and like Adie and Amanpour, she favors dramatic events. She rides a train into an Indian city stricken by plague as its citizens flee the other way. She visits a group of depressed young people in Ukraine and watches in a kitchen in Odessa as they inject themselves with a toxic form of heroin known as chorny. She describes flesh-eating, antibiotic-resistant bacteria devouring a patient in an American hospital. She recounts the frustrations and triumphs of the epidemiological SWAT teams that fly in from the Centers for Disease Control, the World Health Organization, and other institutions when outbreaks of such horrors as plague or Ebola occur.

Everywhere Garrett encounters hospitals in chaos. When plague spread to several Indian states and killed some eighty people between August and October 1994, Garrett shows how the situation was exacerbated by a slow and lazy response from the Indian authorities and from the top officials of the World Health Organization, as well as by dilapidated, poorly equipped laboratories. Mass hysteria among panicky doctors and the residents of Surat made it even harder for the medical services both within and outside the country to respond efficiently. In 1995, 315 people contracted Ebola hemorrhagic fever and 244 people died in Kikwit, Zaire. This disease is caused by a virus, which is present in the bodily fluids of infected people. Health workers caring for sick and dying patients and relatives preparing the dead for burial tend to be most at risk for the disease. In Kikwit, two thirds of the dead were health workers who lacked such basic supplies as rubber gloves. In Russia’s notoriously grimy hospitals, Garrett found that infection control was weak or nonexistent. Even US health care is undermined by doctors who overprescribe antibiotics, so that bacterial infections are increasingly resistant to the most widely used ones. If present trends continue, she writes, eventually few, or even none, of these drugs will work.

Terrible as the case studies in Garrett’s Betrayal of Trust may seem, today’s public health crisis, at least in developing countries, may be worse than she makes it out to be. Even in Surat, Kikwit, and Uganda, where another Ebola outbreak recently killed 224 people, most premature death is related to contaminated water, malarial mosquitoes, unsafe sex, and malnutrition. Plague and Ebola are rare; horrible as they are, they take relatively few lives. Even in Surat, despite the chaos that erupted during the pneumonic plague outbreak, the health system didn’t perform that badly in the end. The outbreak was brought under control within a week, and although about fifty Suratis died, this is historically a relatively modest death toll. In the first ten years of the twentieth century, plague killed over six million Indians.

Health care in developing countries is truly in chaos, but the evidence for this does not lie primarily in the flawed response to occasional outbreaks of Ebola and plague. What really testifies to the collapse of global public health are the weak responses to the millions of deaths from measles, malaria, diarrhea, malnutrition, pneumonia, AIDS, tuberculosis, and other preventable or curable diseases that occur every year in villages, urban squatter settlements, and refugee camps throughout the world, a disaster that often, with the exception of AIDS, goes unremarked by newspapers and television.

For Garrett, the plague and Ebola outbreaks are important because they warn of an approaching apocalypse. Like the storms and floods that presage global warming, these catastrophes are signs of growing extremes in the socio-economic climate, including widening economic inequality, increased polarization between rich and poor, and reduced investments in health care everywhere:

If the passage of time finds ever- widening health gaps, disappearing middle classes, international financial lawlessness, and still-rising individualism, the essential elements of public health will be imperiled, perhaps nonexistent, all over the world.

Garrett’s important message is weakened by a tendency toward overstatement. For example, she quotes without comment a source who claims that 800,000 Russians, or 5 percent, will be HIV-positive by the year 2000. In fact, 800,000 people (a realistic, if slightly inflated, estimate of the number of HIV-positive people in Russia today) is only 0.5 percent of the population of Russia. She also quotes without comment a Ukrainian doctor who says that by 2012, 70 percent of Odessans will be HIV-positive. Ukraine and Russia have serious HIV epidemics, but the infection is still confined largely to intravenous drug users and sex workers and their sexual partners, and has not spread widely in the general, non- drug-using population. Whether it does by 2012 depends on future patterns of drug use, sexually transmitted disease, and other circumstances that raise the risk of infection. Another source claims that by the year 2000, TB rates will increase fifty-fold in Russia (they have in fact increased 80 percent since 1990, mainly among prisoners).

Betrayal of Trust contains similar dire predictions about the spread of food poisoning and the collapse of hospitals in the US, but since Garrett does not qualify or explain these predictions, readers might find themselves wondering how reliable her forecasts really are.⁵She is right that many political leaders lack the will to build better health systems, and that their countries would be better off if they invested more in vaccines, infection control, disease surveillance, and other public health activities. But Betrayal of Trust does not deal with the specific conditions that make it difficult or impossible for many governments to spend more on health. She does not explore the role of the World Bank and the IMF, which have lent large sums to poor governments but have also required many of those governments to reduce spending, which has usually meant cuts in social services such as health and education and infrastructure projects such as drainage and water supply. She discusses the pharmaceutical companies that arbitrarily price their drugs out of the reach of billions of poor people who need them; but she does not inquire into the transnational corporations, donor governments, banks, local businesses, and other institutions that often create enormous political and economic obstacles to better public health.

2.

Three new collections of essays on the health of the world’s poor, Dying for Growth, Poverty, Inequality, and Health, and Challenging Inequities in Health, explore these questions in great detail. In particular, the various contributors to Dying for Growth trace the current crisis in global public health back at least forty years. Many poor countries became independent during the 1960s, and popular support for their new governments was often based on promises by local leaders to redress the inequities of colonialism with extensive social welfare programs, including free health care and education. Western governments used World Bank loans, among other purposes, to gain leverage in the developing world during the cold war. Then, when oil prices rose in the early 1970s, commercial banks, flush with petrodollars, gave more easy loans to many developing countries. Some of this money went toward social services. But substantial sums were also spent on wasteful industrial and other development projects, often designed by Western advisers; and still more money was stolen by corrupt government leaders.

By the late 1970s, it became clear that many poor nations could not repay their loans either to the World Bank or to the commercial banks. The World Bank and International Monetary Fund, influenced by Margaret Thatcher and Ronald Reagan in the 1980s, established a new lending formula for poor governments, known as structural adjustment. Poor governments could borrow money from the World Bank, but the loans came with certain conditions, designed, among other purposes, to maintain the value of the currency in which the loans would be repaid. Borrower nations were required to reduce or eliminate protective tariffs and other trade barriers, privatize their industries, and emphasize the production of exports rather than goods for the domestic market. Most borrower countries were also required to cut spending, which meant that health and education budgets fell. That lending formula was meant to encourage developing economies to grow, particularly in the export sector, so that they could earn more foreign exchange. The aim was also to bring developing and developed economies closer together through increased trade and investment. The overall purpose was to try to ensure that poor countries would be able to service their debts to international lenders, such as the World Bank itself.

The authors of the essays in the three collections under review show how these policies often harmed the poor. Today per-capita income in many developing countries is lower than it was fifteen years ago, and average living standards in most of them have declined since the mid-1980s. Health status is declining along with incomes. Between 1950 and the late 1970s, life expectancy increased by at least 10 percent in every developing country in the world, or, on average, by about fifteen years. However, today life expectancy remains below fifty in more than ten developing countries, and since 1970 it has fallen, or barely risen, in Uganda, Tanzania, Zambia, Zimbabwe, and Malawi. Infant mortality in 1999 was actually higher than it was in 1990 in Zambia, Cote d’Ivoire, Cameroon, Cambodia, Kenya, Zimbabwe, South Africa, Botswana, and Belarus.

The AIDS epidemic and armed conflict are both partly responsible for worsening health in much of the developing world, but failed development policies must also share some of the blame.⁶ Structural adjustment promoted large-scale industry and agriculture, often at the expense of local enterprises, which employ 80 percent of workers in developing countries. In Haiti and Ghana, for example, trade barriers were lowered, which reduced food prices for a while; but the flood of cheap imports put thousands of small farmers out of business, and then high inflation caused food prices to rise again anyway. In Zimbabwe, interest rates rose to 50 percent after structural adjustment was imposed, making it impossible for many small businesses to survive. In Bangladesh, privatization of the jute industry led to a 50 percent reduction in output and the loss of 39,000 jobs.

In many countries where structural adjustment was imposed, already fragile health systems disintegrated further. In Zaire, 80,000 teachers and health care workers lost their jobs in the 1980s, while in Ghana the number of doctors fell by half. In Senegal the number of nurses fell sixfold, so that by 1990, there was only one nurse per more than 13,000 people. In the early 1990s, Zimbabwe laid off 7,000 nurses and thousands of teachers. Inflation slashed public-sector salaries, and many doctors left the country.⁷

The World Bank also required health services throughout sub-Saharan Africa and in certain countries in Asia and Latin America to charge patients “user fees” at public health facilities, to make up for reduced government health spending. The World Bank knew these fees would be prohibitively high for many people, so health services were also encouraged to offer waivers for the poor. The bank now admits, “In most African countries, such exemptions tend to benefit wealthier groups (such as civil servants).”⁸ Studies in Kenya, the former Zaire, Nigeria, Zimbabwe, and other countries have shown that attendance at health facilities by the poor dropped sharply within days after the introduction of user fees.⁹ In Zimbabwe a doubling of deaths in childbirth has been attributed to the introduction of user fees in public maternity wards. At the same time, the collapse of health services and the introduction of user fees meant that sexually transmitted diseases such as syphilis and gonorrhea were probably more likely to go untreated. These diseases create sores in the genitalia that make it much easier for HIV to spread from person to person; untreated sexually transmitted diseases may largely explain why HIV is so widespread in Africa.¹⁰

Structural adjustment loans also required governments to privatize state industries, which meant there was even less money to spend on health, education, and infrastructure such as sewers and water works. The new loans also increased the sums owed by poor countries to foreign creditors, and by the mid-1990s the African continent was transferring four times more in debt repayments than it spent on health or education. At the same time, in the midst of the AIDS epidemic, per-capita aid to Africa from rich nations fell by around 40 percent. Under pressure from poor governments, Western activists, religious leaders, and liberal politicians, some loans are now being forgiven, but far more remains to be done.

Even where structural adjustment was not formally imposed, similar policies were sometimes adopted, with similar consequences for health services and for the health of the poor. In Russia, Western economic advisers and the IMF persuaded Boris Yeltsin’s government to pursue economic liberalization in the early 1990s. Price controls were relaxed, industries were privatized, and government spending was cut. As is well known, the results have been a disaster, partly because the institutions that sustain a free market, such as a strong legal system and some form of social welfare, were absent. Moreover, relaxed banking regulations made it easy for corrupt officials and businessmen to siphon huge sums of loan money into foreign bank accounts. No wonder the Russian health care system is disintegrating before journalists’ eyes.¹¹

Since China’s economy became more integrated with the world market twenty years ago, health overall has improved, but poverty is deepening in rural areas, and infant mortality among the rural poor actually increased by 25 percent between the 1970s and the late 1980s. A similar economic transition introduced in Vietnam in 1986 led to the collapse of many agricultural cooperatives that once provided health care. Today, one third of all poor Vietnamese people cannot afford care.

Western governments and banks urged poor countries to encourage foreign investment, and multinational corporations moved in to take advantage of the enormous number of people willing to work for very low wages. These industries brought welcome jobs to some workers, but they also brought hazards. For example, Mexican workers in the US-owned factories called maquiladoras live in squalor resembling nineteenth-century Bermondsey, where they are more vulnerable than other Mexicans to diarrheal disease, dengue fever, and tuberculosis, not to mention murder and rape and other crimes associated with the drug trade that also flourishes on Mexico’s border.¹²

Some companies brought other health problems with them. Indigenous people in Ecuador were exposed to toxic waste dumped there by US oil companies; workers in South Africa and Mexico were exposed to high levels of the cancer-causing poison chromate in German chemical factories; gas flares in Nigerian oil fields run by Western companies released levels of soot and pollution that would be illegal in the United States and Europe and devastated the environment of the Niger delta. When Nigerian citizens complained about the activities of the oil companies, the government of Sani Abacha executed some of their representatives.

The essays in Dying for Growth, Challenging Inequities in Health, and Poverty, Inequality, and Health help to explain the causes of some of the chaos that Garrett observes in the health care systems she writes about. But they also demonstrate just how dependent human health is on factors that have little to do with health care as such, including economic policies, labor conditions, trade, unemployment, environmental policies, government debt, corruption, and much else besides.

In his introduction to Dying for Growth, Paul Farmer rages against the “fecklessness of the powerful,” and says he hears the “bitter recriminations of the powerless” in his daily work as a doctor and public health expert in Haiti, Peru, and other countries. But in the end, it is not clear whom Farmer wants us to hold accountable for the suffering of the poor—Western neo-liberal politicians? corporation heads? shareholders? bank presidents? IMF and World Bank economists? corrupt or indifferent government leaders? These people come and go anyway, and their power often depends on the power of others. Maybe what really needs to change is the conviction, implicitly held by many of these people, that it is primarily Western creditors who need protection when poor economies stagger or fail.

3.

Russia’s Bolshevik leaders promised that the horrors visited on the working class in nineteenth-century Europe would vanish under communism. In some important respects, this promise was kept. Since the 1917 Revolution, life expectancy in Russia has roughly doubled, infant mortality has fallen tenfold, and diseases that were common in tsarist times, including malaria, typhoid, and smallpox, are now rare or nonexistent. The current health crisis in Russia, which began in the 1960s and accelerated in the 1990s, is therefore particularly troubling.

Russia’s own statistics indicate that life expectancy for Russian men fell by nearly eight years between 1965 and the mid-1990s, and by about one year for women over the same period. Such steep declines in life expectancy are rare in the absence of a severe epidemic like plague in the Middle Ages, or AIDS in sub-Saharan Africa today. But no similar infectious epidemic has been spreading across Russia.

Some observers have blamed lack of investment in Russia’s health sector for this crisis. What is striking, however, is that while Russian death rates overall have risen since the 1960s, the principal cause of this increase is a huge wave of premature deaths among adults, mostly men, between twenty and sixty-five years of age. This death wave crested in the mid-1990s, shortly after the breakup of the Soviet Union. At the same time, death rates among children and the elderly, although higher than they should be for an industrialized country, have remained stable or fallen slightly since 1990, as have deaths among women giving birth. Since children, the elderly, and women giving birth are the most likely to seek and require medical care, the horrendous state of Russian health services, the grimy hospitals, plunging vaccination rates, and lack of health education may not be the most important factors responsible for Russia’s current health crisis.

Recent research confirms what Western observers already suspected in the 1980s.¹³ Death rates from alcoholism, homicide, suicide, accidents, falls, burns, drownings, poisonings, and other forms of intentionally violent or accidental death have risen, as have a number of killer diseases that particularly affect people living on the edges of society. For example, tuberculosis rates have increased 80 percent in Russia since 1990, but mostly among prisoners in overcrowded jails. AIDS, syphilis, and other sexually transmitted diseases are also spreading among drug users and sex workers and their clients. Deaths from heart disease and stroke, which usually strike in old age, now afflict and kill Russians at younger ages than they did in the recent past, perhaps because of psychological stress and alcoholic bingeing.¹⁴

What is worth noting is how much of Russia’s health crisis has been the result of self-destructive behavior. Twenty years ago, the writer Nicholas Eberstadt suggested in these pages that decades of totalitarian brutality, combined with the failing socialist economy of the 1970s, which repaid the efforts of its workers with worsening living standards, created a cynical population that increasingly sought dignity in quiet alcoholic rebellion.¹⁵ Russia’s citizens may well see the neoliberal reforms of the 1990s as the poisoned fruit of yet another empty ideology. As prices go up and wages dwindle or even fail to materialize at all, they seem to reserve whatever enthusiasm remains for the vodka bottle.

The death rate in Russia is closely linked to Russia’s economic fortunes, as would be expected since it seems to be driven less by trends in longstanding, progressive diseases like cancer than by sudden, short-term afflictions associated with psychological stress. Russian mortality rose between 1990 and 1994, but then fell between 1994 and 1998. These fluctuations in mortality have been most pronounced in urban areas of European Russia, where the effects of liberalization have been felt most strongly; that is, where increases in economic inequality, labor turnover, and crime have been greatest.¹⁶ Perhaps, suggests Martin McKee in Poverty, Inequality, and Health, death rates fell after 1994 as people began to adjust their expectations to the economic crisis of the early 1990s. But then the death rate began to rise again in 1998, after yet another economic crisis caused a new round of layoffs and sharp price increases. This may illustrate how closely linked the health of the Russian people is to the sudden crises brought about by the policies of international financial institutions and foreign governments, the price of oil and other commodities, and by the defective economic policies and corruption of Russia’s own government.

Risky and self-destructive behavior is an increasing cause of rising death rates among certain groups of poor adults in many countries, not just Russia. Several of the articles in the books under review show that while children and old people in poor countries remain at much higher risk of death than their counterparts in rich countries, their situation is in some cases improving, and is usually not becoming dramatically worse (except of course where rates of HIV infection are high). On the other hand, death rates among younger adults and adolescents are rising in many places, and very often they are dying by their own hands. According to the predictions of the World Health Organization, by the year 2020, six of the top fifteen causes of death in the world will be suicide, violence (including homicide, rape, and war), injuries (including poisonings, drownings, industrial accidents, car crashes, falls, and burns), and diseases associated with risky behavior such as AIDS, lung cancer caused by tobacco smoking, and liver cirrhosis caused by alcohol abuse.¹⁷

These fatal trends are emerging in a world that continues to fail to help the poor improve their lives. Just as in Russia, increasing self-destructive behavior in other countries may be linked to economic change. The AIDS epidemic in Africa may turn out to be the worst health crisis in the history of the human race. It is not known where this disease came from, but during the 1980s economic policies that emphasized exports, often at the expense of rural farms and small businesses, upset the equilibrium of African communities and probably contributed to the creation of a social ecology favorable to the spread of HIV by swelling already significant waves of migration south of the Sahara.¹⁸ The region’s cities are now the fastest growing in the world, and rapid urbanization, along with widespread sexually transmitted diseases, have been among the causes of Africa’s AIDS crisis.

For example, in Tanzania, cuts in education spending, mandated by its structural adjustment program, have caused a dramatic rise in school drop-out rates, from near zero in 1979 to around 40 percent today, and 70 percent in rural areas. Poor, uneducated adolescents and young adults find occasional work in mines, on plantations, and on urban streets, but their lives are precarious. Vinand Nantulya and colleagues at the African Medical Research Foundation interviewed some of them and found widespread and intense feelings of despair. “To be an adolescent is like living in Hell,” one of them said in a focus group. “People refer to us as [thugs]; whatever effort we make to survive, they criticize.”¹⁹ A group of African prostitutes told researchers from a British charity that one of the reasons they sell sex is to pay their children’s school fees.²⁰

Throughout sub-Saharan Africa, HIV infection is most common in places like the mines and plantations and urban squatter camps where these young people live and work, and where the wealth of the globalized economy meets extreme poverty. Even where surveys show that nearly everyone knows about HIV and how it is transmitted, the virus continues to spread among lonely migrants, sex workers, and an impoverished, underemployed population. A recent study from South Africa found that 60 percent of women between twenty and thirty years of age who lived in a poor township near a gold mine were HIV-positive. These women were not sex workers. Twenty-two percent of them said they had had only one sex partner in their entire lives.²¹

Another sign of disaffection among the young is soaring rates of drug abuse throughout the former Soviet Union, as well as in South and Southeast Asia, Latin America, and Central and Southern Africa. Rising drug abuse is partly the result of increased trafficking, which in turn has been partly the result of economic liberalization. Bank deregulation, business privatization, and the failure of weak or war-torn governments have all provided opportunities for criminals involved in money laundering and illicit sale of drugs and guns.

More young people also seem to be turning to suicide. In Great Britain, suicide rates among young men aged fifteen to twenty-four have roughly doubled since 1970. Suicide rates among young men have also risen, though to a lesser extent, in other industrialized countries, including the US, Canada, New Zealand, Australia, Finland, Norway, France, Belgium, the Netherlands, Austria, Spain, Italy, and Switzerland.

In a chilling essay in Poverty, Inequality and Health, Claudio Lanata describes desperately poor women in the shantytowns of Lima, Peru, where migrants from the countryside seeking a better life in the city often end up, and then find themselves isolated and in limbo. The women Lanata describes feel so depressed and hopeless that they don’t take their sick infants to accessible health services that could save them, and many of their babies die.²²

It is as though poor adolescents and adults, upon whom developing societies traditionally depend, were looking for ways to kill themselves. Stark and increasing inequalities in many countries may be affecting how young people see themselves, how they perceive their self-worth, and their abilities to take action. These inequalities may also be subverting their will to survive. Perhaps these young people are internalizing the verdict of global economic forces that do not need or care about them. Perhaps their condition also has something to do with what Emil Durkheim in his book Suicide called “anomie,” or the breakdown of the collective conscience that regulates human affairs. The powerful institutions that increasingly govern all our lives have thrown the lives of the poor into flux, and nothing has emerged that might soften the blows of the economic, social, and personal crises which these institutions themselves increasingly cause.²³

People in richer countries tend to be generous to poor victims facing sudden disasters, such as earthquakes or wars in faraway places, or, for that matter, sudden outbreaks of pneumonic plague or Ebola virus. But they have been far more indifferent to the suffering caused by persistent poverty. Perhaps this is because earthquakes, floods, and the Ebola virus seem like acts of God, and wars seem like acts of inhuman cruelty and stupidity, and both seem as if they come from some other world than our own. Persistent poverty does not arise by chance, or from the cruelty of some particularly brutal warlord. Deadly poverty arises out of unfair social and economic arrangements. The message of all the books discussed in this review is that we must address these flawed policies as we would any other type of disaster, even though we are also aware that these policies have many benefits, including cheaper commodities and higher company profits, stock prices, and bank dividends that make modern lives for some of us more agreeable.

Partly in response to criticisms over the human costs of its economic and development policies, the World Bank began to place greater emphasis on the health and well-being of the poor in the early 1990s. The bank’s mission remains the promotion of economic growth, but it says it is now doing so with greater mindfulness of the sometimes deleterious effects of growth-promoting policies. It remains to be seen what effect this new emphasis will have. In his lectures at the World Bank in the mid-1990s the Cambridge economist Amartya Sen attempted to persuade economists, businessmen, and politicians to care more about human beings, not because of what they produce, or how they can be exploited, but because there is intrinsic value in what he calls “human capability.”²⁴

Development programs, he writes, must try not only to raise average incomes, but also to give people “the freedom to lead lives that they have reason to value.” By this he means not only freedom from human rights abuses, political oppression, malnutrition, disease, environmental pollution, unemployment, and other forms of human misery, but also the freedom for each person to realize his or her own possibilities. Sen does not say how these utopian goals will be achieved, or even if they can be. Perhaps he is being a little delicate about it, but he seems to suggest his listeners could start by deciding just how much they think a healthy, meaningful human life is worth.