Plagues and the Paradox of Progress

Plagues and the Paradox of Progress

For the first time in recorded history, bacteria, viruses, and other plagues and pestilence do not cause the majority of deaths or disabilities in any region of the world. Curbing infectious diseases has extended lives and prevented child deaths in poor societies, but also brought new and unexpected challenges—like rising youth unemployment, overcrowded and underbuilt cities, and surging rates of premature chronic diseases—that many nations are unprepared to handle. In Plagues and the Paradox of Progress, Thomas J. Bollyky traces the rise and fall of infectious disease in human history and the challenges and opportunities that unprecedented health achievements pose for our future.

March 1, 2019 4:10 pm (EST)

Teaching Notes


Plagues and parasites have played a central role in world affairs, helping to shape the evolution of the modern state, the growth of cities, and the disparate fortunes of national economies. Now, for the first time in recorded history, viruses, bacteria, and other infectious diseases are not the leading cause of death or disability in any region of the world. People are living longer, and fewer mothers are giving birth to many children in the hopes that some might survive.

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Yet, 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. Without that broader development, 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 sources of impoverishment and instability instead of the drivers of prosperity and inclusion that they should be.

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Public Health Threats and Pandemics

Infectious Diseases

Better health and the decline in infectious disease deaths has allowed  poor world cities to grow rapidly, but that growth is far outpacing the infrastructure in those cities, leaving nearly a billion people living in slums. The young adult populations of many lower-income nations is growing faster than their income or job opportunities, spurring instability and desperate attempts at migration. While fewer people are dying from plagues and parasites today, heart disease, cancers, diabetes, and other noncommunicable diseases are surging in poor countries, in some cases at rates that are three to four times faster than ever seen in wealthy nations.  

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.

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.

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This book is suitable for the following types of undergraduate and graduate courses:

  • Global Health
  • International Development
  • International Relations

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Public Health Threats and Pandemics

Infectious Diseases


Discussion and Essay Questions

Courses on Global Health

  1. Why has the history of the decline in infectious diseases been at least as consequential as the story of their rise?
  2. What was the purpose of early international health campaigns, such as the Spanish Royal Philanthropic Vaccine Expedition, and colonial medicine? How have donor and intergovernmental institution interventions in health changed over time?
  3. How has the path to progress against infectious disease in low- and middle-income countries differed from the path taken by wealthier nations in the past? What are the consequences of those differences?
  4. Has the threat of infectious disease declined in low- and middle-income countries? If so, how should the role of global health efforts change?
  5. What role, if any, should international initiatives play in addressing the rise of noncommunicable diseases in low- and middle-income countries?
  6. Why did the Ebola outbreaks in 2014 and 2018 cause significantly more cases and deaths than the twenty-eight previous outbreaks of that disease?


Courses on International Development

  1. Is the way that progress is occurring against infectious diseases in low- and middle-income countries different from past improvements in wealthier nations? If so, what are the any consequences of those changes?
  2. How have efforts to control infectious disease, such as quarantine and compulsory smallpox immunization, helped shape the evolution of the modern state? What role has clean water and sanitation played in the evolution of municipal governments?
  3. Does improved health produce greater economic development? If so, under what circumstances? What role did improved health play in the economic rise of China?
  4. How have improvements in health and child survival affected urbanization in low- and middle-income countries in recent decades?
  5. What is the relationship between improved health and child survival and migration patterns in recent decades?
  6. Discuss the debate over whether global health initiatives reduce the responsiveness and accountability of recipient governments. Are there alternatives to letting infectious diseases and other plagues of poverty run their course or having donors to insert themselves between governments and their constituents?


Courses on International Relations

  1. How have the traits of infectious diseases—that these diseases can spread and disproportionally affect previously unexposed people—motivated international cooperation?
  2. What was the purpose of early international health campaigns, such as the Spanish Royal Philanthropic Vaccine Expedition, and colonial medicine?  How have the reasons why donors and intergovernmental institutions intervene in the health of people in other countries changed over time?
  3. What led states to begin negotiating international agreements on infectious disease control in the second half of the nineteenth century?
  4. What early institutions emerged to facilitate international health cooperation?
  5. What role should the United States play in helping other nations confront the demographic challenges—population growth and rapid urbanization— that have emerged as health has improved in other nations?
  6. What international arrangements exist for responding to dangerous infectious disease events?
  • What measures were taken to improve global health security after the 2014 Ebola outbreak?
  •  Are we better prepared today than in 2014?
  • What additional steps should be taken?


Further Projects

Policy Brief

Please write a two-page policy brief to the president on why the United States should do more to address the rise of noncommunicable diseases in low- and middle-income countries, and propose three concrete measures that the United States should undertake.

Analytical Essay

Write a 1,500-word essay on one of the following subjects:

  1. Under what circumstances should donors and intergovernmental institution provide global health assistance to autocracies and repressive nations? If those nations become more autocratic and repressive, what steps can and should global health donors take?
  2. Does the evolving global threat environment require adjustments in traditional U.S. conceptions and practices regarding global health?
  3. If the goal of global health can be characterized as giving people the opportunity to live healthier and more productive lives, have global health initiatives been successful? What are the appropriate metrics for this definition of success?
  4. If successful global health initiatives have contributed to increased urbanization, higher rates of youth employment, and more emigration from poor countries, was engaging in those global health initiatives a mistake?



  1. The health needs of low- and middle-income nations are shifting to noncommunicable diseases, many of which have risk-factors such as tobacco and alcohol use that are associated with commercial industries. This shift has raised questions about the appropriate role of the private sector in the future of global health. 
  2. In 2015, the World Health Organization estimated that obesity is now the fifth-largest cause of death worldwide, causing 8 million deaths per year. The role of the food and beverage industry in that epidemic is a subject of much debate. For its partisans, the food and beverage industry has necessary expertise and is a willing and capable partner in the fight against global obesity. For its opponents, the food and beverage industry is hopelessly conflicted on this issue and has quietly undermined, both domestically and internationally, efforts against obesity. Please debate the following two propositions.
  • Governments and intergovernmental institutions should not allow any person employed by the processed food and beverage industry or any entity working to further its interest to be a member of any body, committee or advisory group that sets, recommends or implements global health policies with respect to obesity.
  • Governments and intergovernmental institutions should not allow any person employed by the processed food and beverage industry or any entity working to further its interest to be a member of any body, committee or advisory group that sets, recommends or implements global health policies in general.


Supplementary Materials

Paul Bairoch, Cities and Economic Development: From the Dawn of History to the Present (Chicago: University of Chicago Press, 1988).

Mark Nathan Cohen, Health and the Rise of Civilization (New Haven, CT: Yale University Press, 1989).

Angus Deaton, The Great Escape: Health, Wealth, and the Origins of Inequality (Princeton, NJ: Princeton University Press, 2013).

Edward Glaeser, Triumph of the City: How Our Greatest Invention Makes Us Richer, Smarter, Greener, Healthier, and Happier (London: Pan Books, 2012).

Mark Harrison, Disease and the Modern World: 1500 to the Present Day (Cambridge: Polity Press, 2004).

Timothy J. Hatton and Jeffrey G. Williamson, “What Drove the Mass Migrations from Europe in the Late Nineteenth Century?” Population and Development Review 20, no. 3 (Sep. 1994): 533–559.

William H. McNeill, Plagues and Peoples, 3rd ed. (New York: Anchor Books and Random House, 1998).

Martin V. Melosi, The Sanitary City (Baltimore: Johns Hopkins University Press, 2000).

Randall M. Packard, A History of Global Health: Interventions into the Lives of Other Peoples (Baltimore: Johns Hopkins University Press, 2016).

Dorothy Porter, Health, Civilization, and the State: A History of Public Health from Ancient to Modern Times (New York: Routledge Books, 1999).


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