Chapter 1
The Quiet Revolution: How Life Gets Better While We're Not Looking
In a world dominated by doom-scrolling and crisis headlines, Charles Kenny's "Getting Better" offers a startling counternarrative that feels almost revolutionary in its optimism. While Bill Gates calls it a "needed antidote to aid pessimism," the book's impact extends far beyond development circles. Celebrities from Bono to Angelina Jolie have championed its message, and its influence has quietly reshaped how organizations from UNICEF to the Gates Foundation frame their missions. The book's central thesis-that quality of life is improving dramatically worldwide even where economic growth remains elusive-challenges our fundamental assumptions about progress. As you read about children surviving illnesses that would have killed them a generation ago and girls attending schools their mothers couldn't access, you'll discover a profound truth: the most important story of our time might be the one we're not telling.
Chapter 2
The Paradox of Progress: Income Divergence Amid Quality of Life Convergence
The global development narrative has been dominated by economic pessimism. From the political right, developing nations are dismissed as "Third World rat-holes," while the left blames Western neo-imperialism for persistent poverty. Both perspectives focus on a genuine economic reality: the growing income gap between rich and poor nations. What economists call "Divergence, Big Time" has seen the ratio between the richest and poorest countries expand from 4.5:1 in 1850 to a staggering 127:1 by 2008.
This income divergence appears to justify development pessimism. After all, we care about income because poorer people typically die younger, have higher child mortality, lack education access, and face more violence. With incomes diverging, many conclude quality of life must also be diverging.
Yet this narrative misses a remarkable countertrend. While economic gaps have widened, quality of life measures show dramatic convergence. Consider the evolution of life expectancy: from universally short lifespans in preindustrial times, health in Western countries improved and diverged from the rest of the world until around 1900, when a rapid global catch-up began. This pattern appears even among the famous and powerful-from Henry VIII and the Jiajing Emperor both dying in their 50s in the 16th century, to Queen Victoria reaching 81 while China's Tongzhi Emperor died at 18 from smallpox (a disease Britain had mandatory vaccination against), to both Britain's Queen Elizabeth and China's former premier Jiang Zemin thriving into their 80s today.
This growing equality in quality of life extends beyond health to education, rights, and infrastructure access worldwide. The world's poorest are still poor-but they're living longer, healthier, more educated lives than ever before, and the gap between their experience and that of the wealthy is narrowing rather than widening. This paradox of diverging incomes alongside converging quality of life forms the central mystery that Kenny's book seeks to explain.
Chapter 3
The Sticky Problem: Why Economic Growth Remains Elusive
If quality of life is improving worldwide, why does economic growth remain so stubbornly elusive in many regions? The answer lies in the fundamental difference between the types of technologies that drive economic growth versus those that improve quality of life.
Economic growth depends heavily on what Kenny calls "sticky technologies"-not physical inventions like transistors or computers that spread rapidly worldwide, but process technologies or institutions. Paul Romer argues that systems like Walmart's inventory management or Toyota's Production System have had greater economic impact than inventions like the transistor. While traditional technologies flow easily across borders (developing countries have proportionally more televisions and computers than rich nations), process technologies remain stubbornly context-specific. A television works similarly worldwide, but inventory control systems don't. These institutional innovations require adaptation to local contexts and existing systems, making them "sticky" and potentially explaining why some countries remain poor despite access to modern physical technology.
Historical factors compound this stickiness. The stark contrast between Mungo Park's deadly African expedition (where 41 of 43 Europeans died primarily from disease) and Lewis and Clark's relatively healthy American journey (with only one death from appendicitis) illustrates how environmental conditions shaped colonial development. Disease-ridden areas developed extractive institutions with small European elites ruling over indigenous populations, while healthier regions saw mass European settlement with more equitable societies. These initial conditions established institutional patterns that persist in modern economic outcomes.
The slave trade further undermined African development, removing 18 million people and destabilizing governments. Other factors like geography, climate, and rainfall patterns also correlate strongly with modern economic development, showing how ancient conditions continue to shape present prosperity. These deeply embedded institutional constraints make replicating successful growth models extremely difficult, with economists recycling old theories as new solutions while failing to find a universal answer to economic stagnation.
Chapter 4
Escaping the Malthusian Trap: The Global Revolution in Health
For most of human history, populations were constrained by what Thomas Malthus called the "constant tendency in all animated life to increase beyond the nourishment prepared for it." His model suggested birthrates were set by fertility customs, death rates by income, and income by population size. As populations grew, more people farming the same land would produce less food per worker, reducing average incomes and increasing death rates until equilibrium returned. Malthus believed populations inevitably increased until incomes fell to subsistence level, with "sickly seasons, epidemics, pestilence, and plague" serving as nature's population controls.
Historical evidence supported aspects of the Malthusian model. In Britain from 1200-1650, GDP remained stagnant while population changes inversely affected wages-when the Black Death killed much of the workforce, wages rose dramatically, then declined as population recovered. Only with the Industrial Revolution did Britain escape this trap.
Yet today, Malthus's core propositions no longer hold anywhere. There's no significant positive link between GDP per capita growth and subsequent population growth, even in Africa. Countries with rapidly rising incomes don't see life expectancy increase much faster than countries with slower income growth. Similarly, countries with higher birth rates don't experience declining incomes as a result. Improved health has actually driven global fertility decline, with average rates falling from 5.3 to 3.0 births per woman between 1960 and 2005-a trend now present in every region including Africa.
The global escape from the Malthusian trap has been nothing short of revolutionary. Over the past century, global health has improved more than in all previous human history. Average life expectancy rose from 31 years in 1900 to 66 by 2000, with progress affecting even the poorest countries. While divergence in health outcomes between rich and poor countries occurred until the early 20th century, a powerful convergence began around 1930. By 1999, the poorest-performing countries had life expectancies two-thirds as long as the strongest performers, compared to just half in 1950.
Infant mortality has declined dramatically, from nearly one in five children dying before their first birthday in the late 19th century to one in twenty by 2000. By 2000, only 19 countries had infant mortality above 10%, while 46 countries had rates below 1%. Even sub-Saharan Africa, despite economic stagnation and the AIDS epidemic, saw life expectancy increase by 13 years since 1960 and child survival rates improve from 75% to 88%-translating to millions of lives saved.
Chapter 5
Beyond Health: The Global Convergence in Education, Rights, and Security
The revolution in global health has been matched by equally dramatic improvements in education. While a great divergence in literacy levels likely began by the early 18th century, with UK literacy reaching 75% by 1850 compared to under 10% in most developing countries, convergence began in the 19th century. Between 1870 and 1950, global literacy increased from one-quarter to one-half of the world's population, then to four-fifths by 2000. The bottom 20% of countries increased their literacy rates from one-eighth to more than one-half of top performers between 1950-1999.
Female literacy has particularly improved, with the global ratio of female to male literacy rising from 59% to 80% between 1970-2000. The education gap between leaders and laggards has dramatically narrowed. In 1900, the gap was forty-fold, with top countries averaging seven years of schooling while the bottom fifth had less than two months. By 2000, leading countries reached thirteen years of average schooling, but laggard countries saw a nineteen-fold increase, reaching about one-quarter of leaders' levels.
The advance of civil and political rights has likely contributed to improvements in social indicators. Throughout most of history, basic liberties were severely curtailed, but the last two centuries have seen remarkable expansion in both the concept and practice of freedom. We've moved from a world where 38% of the US South's population was enslaved in 1750 to one where slavery is universally outlawed.
Since World War II, rights have been increasingly enshrined in international law through documents like the 1948 UN Universal Declaration of Human Rights. The Polity database, which measures democracy on a -10 to +10 scale, shows significant global improvement from -6.7 in 1820 to +2.9 in 2000. In 1820, 37% of countries scored the lowest possible rating while none achieved the highest; by 2000, only 1% scored the minimum while 21% reached perfect scores.
Violence has declined dramatically over the very long term. Before the agricultural revolution, between 5-30% of deaths were caused by violence, and medieval Britain had homicide rates around 23 per 100,000-three times today's global average. Since the Cold War's end, violence has declined significantly. Battle deaths in interstate wars dropped from over 65,000 annually in the 1950s to fewer than 2,000 in recent years. Traditional wars of conquest have nearly disappeared.
Chapter 6
The Declining Cost of Quality of Life: How Progress Became Affordable
Perhaps the most remarkable aspect of global development is that the relationship between income and quality of life has fundamentally changed. At an income of $1,000, infant mortality fell from 20% in 1900 to 14% in 1940 and 7% in 2000. Countries with $300 GDP per capita in 1999 have the same life expectancy (46 years) as countries with $3,000 GDP had in 1870.
This means the income associated with a given life expectancy has fallen by 90% over 130 years, creating a more egalitarian distribution of health outcomes. In 1870, the predicted life expectancy in a country with $300 per capita income was just one-third that of a $30,000 country; by 1999, it had risen to more than half.
Education shows similar patterns. A country with $800 GDP in 1930 typically had 9% primary school enrollment, while a country with identical GDP in 2000 would see 84% enrollment. By 2000, there was effectively no relationship between income and enrollment at GDP levels above $1,000.
This declining cost of providing good quality of life explains the weak link between income growth and wellbeing improvements. Many countries with stagnant or even declining incomes have still achieved remarkable progress. Haiti's income fell from $1,051 to $752 between 1950-2002, yet infant mortality more than halved from 22% to 7.8%, and literacy increased from 11% to 50%.
The World Bank identified twelve countries where 2005 income was lower than in 1960, with average declines of 27%. Yet these same countries saw life expectancy increase by an average of ten years, literacy rates nearly double, and political rights improve in seven of nine countries with available data.
Vietnam in 2003, with a GDP per capita of just $2,147 (placing it in the bottom quarter globally), achieved nearly 70-year life expectancy, 2% infant mortality, and over 90% literacy with near-universal primary education. These figures significantly outperform historical Britain at similar income levels. A well-spent $2,000 per capita today can provide many elements of the good life that were impossible at that income level in the 1800s.
Chapter 7
The Power of Ideas: How Technologies and Knowledge Spread Globally
Unlike the process technologies that drive economic growth, which spread more like "bricks" than water, ideas and inventions-from ABCs to DPT vaccines-flow more easily across borders with less regard for local customs. These technologies enable more people to live at the same income level in the same country (overcoming the Malthusian trap) while improving quality of life even where income growth is minimal.
The global eradication of smallpox demonstrates how improved health outcomes can be achieved at minimal cost. Once responsible for 300-500 million deaths in the 20th century alone, smallpox was eradicated through a WHO program costing just $312 million over ten years-about 32 cents per person in affected countries. This amount equals the cost of producing five Hollywood blockbusters or one-tenth of Boston's "Big Dig" project.
The most effective health technologies are remarkably simple and affordable: oral rehydration therapy (sugar and salt in water), breastfeeding, and insecticide-treated bed nets ($5 each) could prevent one-third of the 10 million annual child deaths in low-income countries. Similarly, Malaysia and Sri Lanka reduced maternal mortality by 98-99% through rural midwife programs costing less than 0.4% of GDP.
Meanwhile, expensive inputs like hospital beds and doctors show limited correlation with health improvements. The global ratio of hospital beds declined from 4.2 to 3.0 per thousand people between 1960-2005-a period of unprecedented health gains. Vietnam achieves 91% of US life expectancy while spending just 0.4% of what America spends on healthcare per person ($23 versus thousands).
A remarkably consistent global pattern drives quality of life improvements across countries, regardless of economic growth rates, health financing, education levels, or policy choices. Country-specific factors account for only one-seventh of infant mortality changes between 1950-2000, with the remaining six-sevenths explained by the global pattern of decline.
This common pattern suggests an upper limit to the importance of income growth or policy differences in explaining quality-of-life variations. The model resembles Robert Solow's "exogenous growth model," which failed to explain GDP variations but better fits quality-of-life changes driven by global trends where lagging countries rapidly catch up-suggesting the global diffusion of technology and ideas plays a larger role in wellbeing than in income growth.
Chapter 8
Virtuous Cycles: How Health, Education, and Rights Reinforce Each Other
Elements of quality of life like education, health, and rights appear to form a self-sustaining virtuous cycle, creating multiple reinforcing feedback loops that accelerate development. Education significantly impacts health outcomes, while better health enables and spurs educational achievement. Studies in Kenya show deworming programs reduce school absenteeism by 25%, leading to improved academic performance and longer-term economic prospects. In Tanzania, children whose mothers took iodized oil capsules during pregnancy progress through school faster, demonstrating how maternal health interventions can enhance educational outcomes across generations. Similar effects have been observed with vitamin A supplementation and school meal programs worldwide.
These interlinkages extend far beyond health and education into broader social and political spheres. Education promotes democratic preferences by fostering critical thinking and civic awareness, while also reducing domestic violence through women's empowerment and economic independence. Research shows that each additional year of female education reduces domestic violence risk by 7%. Democracy provides crucial protection against war and mass killings, while democratic regimes consistently see faster improvements in life expectancy and literacy rates. For instance, democratic transitions in Latin America led to significant increases in public health spending and educational access. Inequality strongly correlates with increased crime rates, political violence, autocratic tendencies, and lower educational attainment. Countries with high Gini coefficients typically show 20-30% lower college completion rates than more equal societies.
The spread of ideas and innovations has been dramatically facilitated by urbanization and communication technologies. Urbanization has progressed at remarkably similar rates in both fast and slow-growing developing countries, with income growth explaining only 5% of variation in urbanization rates. This suggests other powerful forces drive urban development. Global connectivity extends far beyond television and telephones to encompassing newspapers, periodicals, and increased international travel. The number of international travelers has grown from 25 million in 1950 to over 1.4 billion today, accelerating cultural exchange and knowledge transfer.
In the mid-1800s, governments played minimal roles in public health or education, with universal services nonexistent and advocacy for government expansion or universal rights rare. A century later, most countries had signed the UN Declaration of Human Rights, fundamentally transforming government responsibilities by committing them to provide not only civil liberties but also healthcare, social security, and free education. This shift represents a revolutionary change in social expectations and government obligations.
Even relatively poor countries now provide more extensive services than wealthier nations did historically. Compare Britain's limited social services in the early 1800s, when it was the world's richest nation, to Vietnam's current offerings - modern states are expected to do and manage far more at similar income levels. Vietnam, despite lower per capita income, provides universal healthcare coverage and twelve years of free education. The spread of knowledge about what governments could and should provide has fueled public demand, creating pressure for improved services even in resource-constrained settings. This demonstrates how global standards for government services have evolved dramatically, driven by increased awareness and expectations rather than just economic development.
Chapter 9
Policy Implications: Promoting Quality of Life in a Complex World
Given our limited understanding of growth-inducing reforms and recognizing income as merely a means to improved quality of life, economic policymaking should first adhere to the principle of "do no harm." This means avoiding sacrifices in health, education, freedoms, or livelihoods purely for GDP growth. Instead, policy should prioritize quality-of-life improvements, which often naturally contribute to economic growth through enhanced human capital and social stability.
Governments play multiple crucial roles in technology diffusion across three main channels. First, they can remove bureaucratic obstacles and create enabling regulatory environments that don't impede progress. Second, they can actively regulate private service provision to ensure quality and accessibility. Third, they can directly provide essential services like vaccination programs, primary education, and basic healthcare infrastructure. The evidence shows that even extremely poor countries can afford basic service provision if resources are properly allocated. For example, Haiti spends only $60 per person on government services compared to New York City's thousands, yet a basic health package costs just $5 per head annually. The challenge often lies in resource allocation and institutional capacity rather than absolute scarcity of funds.
Beyond providing services, governments must actively foster demand for quality of life improvements through various mechanisms. Social marketing programs have proven particularly successful - from increasing oral rehydration solution use in Bangladesh to doubling vaccination rates in Philippines through targeted campaigns. Mass media has emerged as an especially powerful tool. MTV's global HIV-prevention campaign reached 800 million homes and demonstrably changed youth behavior in multiple countries. Educational programming like Sesame Street has improved literacy and mathematics skills across diverse cultural contexts, with documented impacts in over 140 countries.
Conditional cash transfer (CCT) programs have emerged as one of the most effective policy tools for expanding demand for health and education services. Mexico's PROGRESA program (later renamed Oportunidades) provides direct cash payments to mothers whose children maintain school attendance and regular health clinic visits. The results have been remarkable: girls' secondary school enrollment increased by 15 percent and boys' by 7 percent. Children participating in the health component were 40 percent less likely to be reported ill and showed improved physical development, growing measurably taller than non-participants. Similar programs in Brazil (Bolsa Familia) and Colombia (Familias en Accion) have shown comparable positive results.
However, while conditional cash transfers effectively boost service utilization, they don't automatically enhance service quality. Several complementary approaches have shown promise in addressing this challenge. These include matching attendance-based payments with service delivery incentives, introducing managed competition between service providers, and implementing community-based monitoring through citizen report cards. Uganda's healthcare report card system offers a compelling example - it increased service utilization by 20% and reduced infant mortality by 33%, achieving these improvements without requiring additional funding through better accountability and resource management.
Success in improving quality of life ultimately requires a coordinated approach combining service provision, demand generation, and quality assurance mechanisms. The evidence suggests that when these elements work together, significant gains are possible even in resource-constrained environments.
Chapter 10
The Global Responsibility: Why and How We Should Help
Why should wealthy nations care about quality of life in poor countries? Self-interest provides the most common justification-greater global stability, friendly diplomatic relations, and larger export markets benefit everyone. Just as domestic prosperity depends on fellow citizens being healthy and productive, global prosperity depends on similar conditions worldwide.
However, the stronger argument is moral: our life outcomes depend overwhelmingly on the accident of birth location. We accept responsibility for reducing inequalities within our borders, yet these borders are arbitrary lines drawn by long-dead diplomats.
Migration offers perhaps the most powerful tool for improving quality of life in poor countries. Lant Pritchett estimates that increasing rich countries' labor forces by just 3% through reduced migration restrictions would add $300 billion to poor countries' welfare-four times current aid flows.
The evidence linking aid to economic growth is weak at best. Most studies find little relationship, though some show positive impacts under specific conditions. Rather than pursuing elusive growth objectives, aid might better focus on directly improving health, education and rights-valuable in themselves and potentially beneficial for long-term economic outcomes.
Given technology and ideas' importance to global outcomes, donors should support research and dissemination of development-friendly innovations. Aid might fund new vaccine development, more robust vaccines that don't require refrigeration, one-time tuberculosis treatments, new prophylactics against malaria or diarrhea, cheap housing materials, or teaching approaches for minimally-trained educators.
The four horsemen of the apocalypse are retreating. Despite a century containing world wars, genocide and mass starvation, absolute income poverty has fallen dramatically while populations have grown. Every region has escaped the Malthusian trap, with more children being educated, people living longer, and liberties expanding. From a long-term perspective, the world is undeniably getting better.
