Book Review

An Inquiry into Well-Being and Destitution

N Engl J Med 1994; 330:1763June 16, 1994

Article

An Inquiry into Well-Being and Destitution
By Partha Dasgupta. 661 pp. Oxford, England, Clarendon Press; New York, Oxford University Press, 1993. $45. ISBN: 0-19-828756-9

The title of this book does not really do it justice -- at least not from the perspective of a medical reviewer. It is not a polemic about the haves and the have-nots, nor is it composed of emotion-laden anecdotes about the human suffering that is so often associated with destitution. Instead, Dasgupta contrasts the positive qualities of well-being with the negative qualities that are the result of destitution, and he provides a comprehensive and in-depth analysis, in the most sophisticated economic terms, of the costs of destitution, poverty, and the deprivation that inevitably results, not only for those who are destitute, but, more important, for societies. What makes the book of special interest to physicians with broad social concerns is the meticulous and penetrating examination of the economic consequences and costs of malnutrition and ill health and of the obligations of society, and government, in the face of such costs.

It is interesting to contemplate that when Gunnar Myrdal, the Nobel prize-winning economist and philosopher, published Asian Drama: An Inquiry into the Poverty of Nations in 1968 (New York: Twentieth Century Fund), he examined the impact on the development of Third World countries of various sectors of the economy -- agriculture, transportation, industry, trade, education, and so forth. When it came to the health sector, Myrdal thought that the economic data available then were insufficient to quantify properly the importance of health to economic development and thus to justify, in economic terms, investment in health care. Instead, he fell back on the notion that providing health care, defined principally as preventing mortality, must be considered a moral imperative.

Dasgupta, making a similar inquiry 25 years later, is equally concerned with moral imperatives and with values in general, and he leaves no doubt that he considers the provision of adequate health care and decent nutrition a moral imperative. But he confronts the economic implications of illness and malnutrition head-on; he has scoured the literature and assembled the data to assess the effects of malnutrition and disease on productivity, and he makes an economic case for providing an adequate diet and decent health care to enhance not only the well-being of the individual but also the well-being of society.

Many other points ought to be made about this book. Although space limitations make it impossible to include them all, at least one deserves mention. In an age when Gunnar Myrdal's son-in-law writes a book that examines in some detail the exorbitant (some say obscene) incomes “earned” by doctors, lawyers, and chief executive officers (Derek Bok. The Cost of Talent: How Executives and Professionals Are Paid and How It Affects America. New York: Free Press, 1993), when Michael Douglas proclaims on the Technicolor screen that there is nothing wrong with greed, and when Michael Milken “pays” for scores of millions of illegally gained dollars by serving some months in a minimum-security prison and is considered a hero by many, it is startling, almost shocking, to encounter an author who states categorically that the human right to a decent diet and good health care is more important than property rights. But it does seem especially timely and relevant when our nation is embroiled in a debate about the right to health care for everyone that can never be taken away.

This is a serious and important book that has almost 550 pages of text and a reference list that occupies 79 pages of fairly fine print. Many of the references are from the medical and nutrition literature. It should go without saying that it is not possible to do justice to such a book in a few paragraphs. Dasgupta is professor of economics at the University of Cambridge and a fellow of St. John's College, but from 1989 to 1992 he served as director of the Program in Ethics in Society at Stanford University (while also serving as professor of economics and professor of philosophy). Anyone qualified to serve in such a variety of posts in these institutions might be expected to produce a book of more than usual breadth and depth -- and, in this case, weight. The book is heavy going; most of the words are familiar, but what they mean in certain contexts is not always clear to this academic economics-disadvantaged physician. Dasgupta does write well, however, and with a light and fluent touch. His book is well worth the effort.

Joel D. Wray, M.D.
Center for Population and Family Health, Columbia University, New York, NY 10032