1The title of this book is taken from John Sturges’ film, The Great Escape, about a group of prisoners-of-war escaping during World War II. The story that Angus Deaton sets out to explain is humankind’s escape from a destiny of deprivation, famine and early death. Beginning with the observation that material living conditions and health indicators have unarguably improved in the last 250 years, the author sheds new light on the period, methodically describing the determinants of these great advances. The fact is that economic progress and improvements in health often bring inequality: “Inequality is often a consequence of progress” (p. 1). For example, some social groups or countries have benefited from medical discoveries before others, thereby widening the gap between them and countries remaining on the margins of the process. This means that improvements in various populations’ standards cannot be studied without studying inequalities. The author sets out to answer the following questions: What are the historical, social and economic determinants of the progress made in health and poverty reduction in the last 250 years? How are progress and inequality related? Is inequality in health comparable to income inequality?
2Though advances in economic conditions and health are a fact (and improvements in the latter have been “just as impressive” as those in the former), much effort has yet to be made. Deaton is careful to point out all the limitations and impediments to this particular “great escape” and to put forward ideas for how to overcome them.
3The work opens with an introduction and is divided into two parts. The first discusses health; the second, developments in, and the current state of, material living conditions, particularly income. In the closing chapter the author lays out his vision of a policy agenda that would effectively help developing countries and individuals who have not managed to “escape.”
4The first chapter offers an overview of the current state and trends in health and inequality indicators across the world’s different regions. The last centuries have been characterized by great progress in different dimensions of wellbeing (life expectancy, health, income) but as the author recalls, this has also meant differences between and within countries.
5The first three chapters of Part I describe the effects of historical developments and medical advances on current and past health indicators. The first great “revolution” took place in the Neolithic Age with the advent of agriculture and population settlement. Agriculture increased the quantity of available food but also brought about new diseases, lower diet diversity, and new, less egalitarian social structures that slowed further improvement of living conditions. Another important change was the development in England and other European countries of medical microbiology and new medical treatments that improved the health of the general population and sharply reduced infant and child mortality. However, the collateral effect of these new discoveries has been to widen gaps in health indicators for rich and poor countries, inequalities that have combined with pre-existing ones for income. The causes of death in poor countries, primarily infectious childhood diseases, are the same as they used to be in developed countries, and treatments and solutions for them were identified long ago. While infant and child mortality has fallen in those regions, many efforts must still be made, especially on the part of local institutions, which need to develop healthcare and prevention systems. Another reason that average life expectancies in the two groups did not converge quickly is the fact that mortality in developed countries also fell, in part due to the reduction of cardiovascular disease.
6The two chapters of Part II discuss changes in material living conditions over the last two centuries. While dispersion in life expectancy indicators is diminishing between countries, this is not the case for income. To illustrate these changes, Deaton first considers the history of the United States, an extreme case in terms of both wealth and inequality but a country that nevertheless underwent many of the same changes as other developed countries. Between World War II and the 1970s, growth, economic prosperity and reductions in inequality and poverty (particularly for older persons and African Americans) occurred simultaneously. However, since the 1970s, growth has been falling and inequality rising. In this case, inequality is fuelled by spectacular increases in income at the top of the distribution, a situation that the author sees as a threat to the country’s politics and above all its democracy. He then presents a panoramic view of material living conditions across the world. The most remarkable phenomenon is the substantial reduction of poverty since the 1980s, fuelled primarily by India and China. This improvement contradicts the pessimistic predictions of the 1960s that demographic growth in developing countries would bring about greater poverty and famine. However, while some countries and above all some individuals have managed to escape poverty, convergence between developed and developing countries is still very far off and has actually been threatened in the last decades.
7In the closing chapter, Deaton discusses measures that countries, institutions and aid agencies wishing to help poor countries should take, and measures that have hitherto been more harmful than beneficial to local populations.
8This work, readily accessible to non-specialists, is also an excellent introduction for all researchers interested in these topics. It offers a fairly complete overview of past and current trends in wealth, health and inequality indicators, drawing on numerous studies from a variety of disciplines, including demography, history, epidemiology and economics. One of the work’s great strengths is the author’s judicious commentary on the concepts used and their epistemological implications, notably poverty and well-being indicators.
