from Global Health Program

Plagues and the Paradox of Progress

Why the World Is Getting Healthier in Worrisome Ways

Global health expert Thomas J. Bollyky explores the paradox in our fight against infectious disease: the world is getting healthier in ways that should make us worry.

Foreign policy analyses written by CFR fellows and published by the trade presses, academic presses, or the Council on Foreign Relations Press.

There is a paradox in global health: the extraordinary progress being made in overcoming the bacteria, viruses, and parasites that were pervasive in poor societies is causing new sources of instability and impoverishment that threaten to undo all the good that has occurred.

Financial Times

“For the first time in recorded history, parasites, viruses, bacteria, and other infectious diseases are not the leading cause of death and disability in any region of the world,” writes CFR Senior Fellow for Global Health, Economics, and Development and Director of the Global Health Program Thomas J. Bollyky in a new book, Plagues and the Paradox of Progress: Why the World is Getting Healthier in Worrisome Ways. But the news is not all good.

The recent dramatic declines in plagues and parasites have not been accompanied by the same advances in infrastructure, job opportunities, and governance that have attended health improvements in the past. That means the byproducts of better health—a growing young work force, less-deadly cities, and a shift in countries' health needs to adults—have become potential risks instead of the drivers of prosperity and inclusion that they should be. For improved health to lead to broader progress, it must be embedded in a larger development strategy, including investment in quality health-care and education systems, making cities more livable, and family planning and reproductive health care.

More on:

Public Health Threats and Pandemics

Infectious Diseases

Today, “the recent gains in infectious disease control in many lower-income nations have been more dependent on international aid and effective medical technologies,” notes Bollyky.

“The growth of many poor world cities is far outpacing their infrastructure, leaving nearly a billion people living in slums. Lack of sufficient jobs for young adults is breeding instability and spurring desperate attempts at migration,” he adds.

While fewer people are dying from plagues and parasites today, “heart disease, cancers, diabetes, and other noncommunicable diseases are increasing rapidly in most developing countries. In 1990, these noncommunicable diseases caused about a quarter of the death and disability in poor nations. By 2040, that number is expected to jump to as high as 80 percent in some of these countries,” he writes.

Bollyky urges policymakers and foreign aid agencies to “make existing aid and health programs less focused on donor-directed inputs—specific disease-reduction targets, years of primary schooling, and ‘dollar a day’ poverty—and more concerned with local outcomes such as learning, capable economies and governments, and better health, especially among the poor and disenfranchised.”

Bollyky’s book can help to save many lives.
Michael R. Bloomberg

“Global health priorities must also include the noncommunicable diseases and associated health risks that now cause the largest proportion of premature death and disability in lower-income nations,” he writes.

More on:

Public Health Threats and Pandemics

Infectious Diseases

A Council on Foreign Relations Book

Educators: Access Teaching Notes for Plagues and the Paradox of Progress.

Also explore Bollyky's interactive reports, The Changing Demographics of Global Health, The Future of Global Health Is Urban Health, and Democracy Matters in Global Health.

Reviews and Endorsements

An EBSCO Health and Medicine Best Seller


If you want to step back and think more broadly about Coronavirus, the Universe and Everything, you could do worse than start with Plagues and the Paradox of Progress, by Thomas J. Bollyky.

Duncan Green, London School of Economics and Political Science.

Bollyky . . . has made a big splash, inviting a refreshing and provocative debate with the publication of his sweeping, ambitious study, Plagues and the Paradox of Progress: Why the World Is Getting Healthier in Worrisome Ways. . . . He brings to the task a remarkable command of history, science, technology, medicine, public health, and political science. Bollyky combines his scholarship with an unusually fluid writing style that invites readers to read more.


The leading killers of human beings are no longer the viruses, bacteria and other microbes that have lurked for millennia in our sewage, in our domesticated animals and in the parasites that bite or burrow into us. . . . This is a remarkable, largely unheralded, achievement. It brings important and little-understood challenges. . . . A remarkable new book addresses these issues. Plagues and the Paradox of Progress by Thomas Bollyky argues that poor countries are struggling with the consequence of their success.

Financial Times

[A] rich, incisive study. . . . A thoughtful reminder of the social, economic and political complexities inherent in sustainable public health.


A thought-provoking book that should be required reading for anyone working in public health or public policy arenas.

Library Journal

A persuasive, readable, and nonpolemical warning about the future of global health. . . . Plagues and the Paradox of Progress provides a smart warning about our future without discounting the successes of our past.

Health Affairs

Bollyky contends that what will be needed to deal with this new health burden is much more than just a revamped health care system. What will be needed is freer trade, more rapid economic growth, a more inclusive educational system, and better governance.

Population and Development Review

Noncommunicable diseases are an urgent global crisis that has been largely overlooked, with deadly consequences. By calling attention to it—and prescribing solutions—Bollyky’s book can help to save many lives.

Michael R. Bloomberg, Founder, Bloomberg LP and Bloomberg Philanthropies; World Health Organization Global Ambassador for Noncommunicable Diseases; Three-Term Mayor, New York City

A remarkable piece of work, superbly researched, beautifully written, and sobering. It should be required reading not only for policymakers and philanthropists but for anyone seeking to understand the great progress that has been made in global health and the significant challenges that remain.

Sania Nishtar, MD, Founder and President, Heartfile; Former Federal Minister, Pakistan

This stimulating new book is a must-read for those who care about our collective future. A well-recognized leader in global health, Tom Bollyky is a powerful advocate at a critical time, but does not shy away from some unsettling truths. Interweaving history, science, economic/development policy, and international affairs, he reveals the promise and peril of how health advances are reshaping our world, and he soundly argues that a safer, healthier world demands that we address this paradox of unintended consequences. We should take heed!

Margaret A. Hamburg, MD, Foreign Secretary, National Academy of Medicine; Former Commissioner, Food and Drug Administration

Plagues and the Paradox of Progress is a readable history of the rise and fall—and worrisome threat—of infectious diseases, as well as the new health threat to developing countries: chronic illnesses. Bollyky provides deep insight into how health challenges will impact the development of lower-income countries. This is an excellent addition to the scholarship on global health.

Ezekiel J. Emanuel, MD, PhD, Chair of the Department of Medical Ethics and Health Policy, University of Pennsylvania; Author, Prescription for the Future

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