The gains in health go well beyond children. Far more mothers are surviving childbirth. In 1990, out of every 100,000 live births around the world, 420 mothers died in childbirth. (In the United States, the figure is around 20.) Just two decades later, in 2011, that number was down to 238—almost cut in half. The number of maternal deaths worldwide has fallen by more than 250,000 per year since 1990, which means that several million fewer mothers have died in childbirth. There are still too many maternal deaths, but developing countries are on the right path.
There’s more. A wide range of diseases are doing less damage:
• Malaria mortality declined 47 percent between 2000 and 2013, saving 4.3 million lives, most of them children under five years old.
• AIDS-related deaths fell from 2.4 million in 2005 to 1.5 million in 2013, a decline of 35 percent in just eight years.
• Tuberculosis deaths fell 33 percent between 2000 and 2013, saving more than 4 million lives.
• Diarrhea killed 5 million children a year in the early 1990s, but by 2013 the number was down to 760,000.3
The improvements in health among the global poor in the last few decades are so large and widespread that they rank among the greatest achievements in human history. Rarely has the basic well-being of so many people around the world improved so substantially, so quickly. Yet few people are even aware that it is happening.
My wife, Carrie, and I saw the beginnings of these changes firsthand when we were Peace Corps volunteers in what was then Western Samoa in the 1980s. One of our friends was a wonderful woman named Malia, who along with her husband, Sione, had, at the time this story begins, eight children.4 They all lived in a small hut, no more than forty feet long and twenty feet wide, in the traditional Samoan style with a thatched roof supported by about a dozen wooden beams made from the trunks of coconut trees, and no walls. They were poor, living off the meager income Sione earned from selling taro and other crops grown in their plot of farmland, several miles up the slopes of the inland mountain range. They didn’t have much in terms of material goods, but Malia had a bright outlook, abundant energy, and plenty of courage.
One day Carrie went to visit Malia and found her in tears. Child number nine was on the way, and Malia couldn’t bear the thought. Sione had not allowed any birth control, and Malia was beside herself with worry. She sensed that, at age thirty-two, with eight children already, this next birth was going to be risky, and she was right.
Carrie did some asking around and learned that a new clinic had opened in a nearby village, and it had a midwife on staff. She and Malia went for a visit. Within minutes, the midwife recognized that Malia’s was a high-risk pregnancy and recommended that she start taking iron folate tablets, come in for monthly checkups, and, most important, deliver the baby in the clinic, not at home. Malia said thanks, but this was not going to fly—Sione might agree to the tablets and the checkups, but not to the birth in the clinic. Tradition was tradition: Samoans began life on the floor of the family home, not in some sterile clinic in another village. She saw little chance that he would agree to break custom and allow the child to be born anywhere but at home.
In some countries, the big issue for safe births is the lack of a nearby clinic, the absence of a road to get there, or the dearth of trained health care workers. Many women die just because they have no way to get to a clinic. Sometimes the issue is prejudice and bigotry, where workers or patients scorn lower-caste women when they arrive at health facilities. In others, the problem is just plain poverty: the family doesn’t have the money to pay for the visit. In Malia’s case, the constraint was cultural values and traditions. Culture dictated that women have lots of children, and they have them on the floor at home, and that’s the way it is.
The wise Samoan midwife had worked with traditional husbands before, and she knew what to do. She proceeded to take the time to visit Malia in her home, with Sione sitting nearby, for prenatal consultations. Over time she gained Sione’s trust, and pointed to the examples of a few local courageous path breakers who had chosen the clinic over the floor. Sione shifted his views.
When the big day came, they piled Malia into the back of a neighbor’s dilapidated pickup truck and got her to the clinic on time. Beautiful baby Rosa arrived a few hours later.
Then the trouble began. Ten minutes after the birth, Malia suddenly began hemorrhaging. She was slipping fast. It could have been a disaster, but she was in a clinic, which had a trained birth attendant and the right equipment and supplies. She lived. At home, she would have died.
Small things. A new clinic in a nearby village. A midwife on staff, skilled not only in delivering babies but also in working with recalcitrant husbands. A husband who, gradually, was willing to modify his view about what he thought was right. A healthy baby, still thriving today as an adult (and now a mother herself). And a courageous—and determined—mother (also still alive today, with no additional children) able to bring her baby home and care for all nine of her brood.
Malia’s story has been repeated in various forms millions of times in recent decades, increasingly so as technology spreads, knowledge grows, clinics are built, health workers are trained, and attitudes change. Millions of lives blossom and thrive in a world where today there is much less extreme poverty.
The roots of the recent gains in health in developing countries stretch back more than two centuries to the improvements in health in Western Europe that began with the Enlightenment and the industrial revolution.5 The combination of increased incomes, improved nutrition, better living conditions, education, and public health interventions for clean water and improved sanitation led to rapid gains in mortality and morbidity. One of the most important breakthroughs was the discovery in 1855 by the London physician John Snow, known now as the father of modern epidemiology, that deadly cholera was being spread by contaminated drinking water.6 Snow’s work, alongside that of several others, led to the development of modern germ theory. This knowledge and the public health interventions it spurred were central to the reductions in child death and improvements in health in Western Europe. The development of vaccines, antibiotics, and other medicines further accelerated progress. Life expectancy in England jumped from around forty years in 1850 to seventy years a century later.7
Initially, these gains were far from global. They were centered almost exclusively in Western Europe, North America, and a few other places such as Australia and New Zealand. Few people in the rest of the world saw much improvement. A huge health gap emerged, mirroring the huge gaps in wealth, education, and other aspects of human welfare that arose in the nineteenth and twentieth centuries. The rich countries saw enormous gains, while poor countries were left behind.
This dynamic began to change in the middle of the twentieth century. Following the end of World War II and the European colonial period, knowledge about good health practices, alongside critical medicines and vaccines, began to spread to developing countries. Child deaths began to fall, disease morbidity began to decline, and life expectancy began to increase, even in most of the world’s poorest countries.
The combination of the dramatic declines in infant mortality, reductions in maternal mortality, and fewer deaths from malaria, tuberculosis, measles, and other diseases is translating into much longer and healthier lives. Whereas in 1960 the typical person born in a developing country could expect to live around fifty years, today their grandchildren will live sixty-five years, as shown in figure 4.2. People born today in developing countries can expect to live one-third longer, on average, than their grandparents just two generations ago. In many developing countries, they can expect to live even longer. Life expectancy at birth in Chile is now a hardy seventy-six years; Vietnam has reached seventy-three years; and Algeria and Jordan, seventy-two years.
The increases in life expectancy come from both the reduction in child mortality and the progress in fighting diseases that affect older adolescents and adults. Without question, the most dangerous years of life are the first ones. The most dangerous day of any life is the first day. If a child lives to age five, his or her chances of living a long and healthy life improve considerably. Life expectancy for someone who reaches age five in developing countries is now a total of around sixty-nine years, up from sixty-one years in 1960.8 Together, the figures on life expectancy at birth and contingent on reaching age five show that more than half the gains in life expectancy at birth are because of the declines in child mortality, and the remainder from reductions in disease and other gains in health that have been achieved for people at older ages.