Low Income, Social Growth, and Good Health: A History of Twelve Countries (review)

In this concise and highly readable book, Riley looks at the various routes to long life expectancy taken by a selection of diverse countries. In many ways, this book is the final panel of a triptych, following from the author’s Rising Life Expectancy: A Global History (New York, 2001) and Poverty and Life Expectancy: The Jamaica Paradox (New York, 2005). Rather than a global overview, or an in-depth case study, this volume compares twelve countries. Two of Riley’s data points, Costa Rica and Sri Lanka, are the canonical examples (along with India’s Kerala state) of good health despite low income, always referenced by un agencies anxious to prove that long life expectancy is not the exclusive dominion of rich nations. Riley’s other ten nations are Japan and Korea (a colonizer and former colony), Panama (neighbor of Costa Rica), Cuba and Jamaica (two West Indian nations with different governmental styles), China and the Soviet Union (socialist economies), Oman and Venezuela (petroleum exporters), and Mexico (exemplifying certain characteristics of income inequality).

What these countries have in common is that all made great strides in health from 1920 to 1960 (except Oman, which, buoyed by oil revenues, transitioned slightly later). Riley employs long life expectancy as a proxy for good health, a crude equivalency, but one unlikely to be improved upon in the same historical context for such a diverse selection of countries. According to Riley, these countries have little else in common. Using deftly juxtaposed examples (for instance, a chapter on Cuba and Jamaica), the book shows how the particulars of each country’s health transition have differed. In Cuba, where most of the pivotal gain in health occurred before the revolution, vaccines and vector control took center stage. In Jamaica, the introduction of latrines and education about hookworm led to wider educational campaigns against other diseases. Differences across chapters (that is, across further international comparisons) are even more pronounced.

What really unifies these diverse examples is the concept of social growth, or the accumulation of social capital, “physical assets plus human knowledge and skills” (3). The importance of knowledge is a thread that runs throughout the book. The profiled countries were better than others “at building the institutions, habits of mind, and behaviors of social growth” (9). Whether discussing pit latrines, the isolation of tuberculosis patients in sanatoria, or the control of malaria-spreading mosquitoes, Riley emphasizes knowledge and the concomitant change of behavior that leads to the institutionalization of norms promoting good health. As a counter to the country-specific studies, the book ends with a chapter discussing three key causes of death—malaria, tuberculosis, and diseases transmitted by fecal contamination. Certainly, these diseases were the common backdrop for the stage of mortality decline, even if the foreground varied from place to place.

The McKeown debate—about the relative importance of nutrition versus health interventions in the historical decline of mortality—persists.¹ Riley has been a voice of reason in this polemic, arguing against particularistic approaches by observing the many interconnected ways in which health has improved. In Low Income, Social Growth, and Good Health, Riley underscores another often-overlooked subtlety, namely, that the recipe can vary for different countries. This point seems a logical corollary of much past research about mortality decline, but people have often avoided connecting the dots, preferring instead to focus on one factor or the other.

One obvious desideratum is to apply the historical lessons of this volume to the present. The region most likely to benefit from the insights of this book is sub-Saharan Africa, as Riley briefly observes in the conclusion. He might have directed more attention, however, to the problems in that part of the world. Riley is well aware that sub-Saharan Africa currently faces an epidemic of hiv/aids, which none of his profiled countries faced during their pivotal periods. But Africa has other problems that are even...