Werner Troesken - The Pox of Liberty: How the Constitution Left Americans Rich, Free, and Prone to Infection: How the Constitution Left Americans Rich, Free, and Prone to Infection

I did not set out to write a book about how the American constitutional order shaped the countrys disease environment and public health programs. Instead, I wanted to answer the questions: How and why have some societies come to control infectious diseases while others have let them fester? I thought there was a straightforward, almost tautological answer to this question, an answer that said strong, well-functioning governments eliminated disease, while weak, dysfunctional governments did not. I wanted, in other words, to argue that there was a simple linear relationship between disease and the quality of governance: good public health systems, like good roads or good public schools, reflected good governance and well-functioning polities, while poor public health systems, like poor roads or poor public schools, suggested inferior governance and dysfunctional polities.

I was attracted to this way of thinking by a casual empiricism. If I looked at Africa, for example, I saw a continent dominated by governments that were either too corrupt or weak to provide basic public goods such as education or public health. That these same places were also impoverished struck me not as a cause of disease, but as a symptom of the same underlying pathology: a dysfunctional state. By the same token, when I looked to richer parts of Asia or Western Europe, I saw stronger, more benevolent states where politicians seemed to have a vested interest in promoting the health and well-being of their citizenry and invested accordingly in the capital and public health systems necessary to combat disease. Given these observations, democratic institutions seemed the obvious solution to high infectious disease rates and poor public health systems. In much the same way that Amartya Sen argues that famines rarely occur in democracies because democratic leaders have stronger political incentives to combat crises than do leaders of autocratic regimes, I wanted to argue that democratic impulses drive polities to provide adequate levels of disease prevention, no matter what the climate or geography or even the level of per capita income.

While I still think there is something to this logic, history suggests that there is much more to good governance than just democracy. As explained in

The Pox of Liberty is my attempt to develop a more complex and multifaceted understanding of the relationship between the structure of the state and infectious disease rates. In developing this line of thought, I have tried to highlight the generality and unintended consequences of constitutional rules and the ideological structures that support and sustain those rules. The import of that analysis is that there is no simple correspondence between the quality of political institutions and public health outcomes. Some political institutions often thought to promote desirable political and economic outcomes can also hinder the provision of public health, and vice versa.

The Commerce and Contract Clauses, for example, were designed to address the problem of factions, powerful political lobbies that captured the state in order to use it to support their own ends at the expense of broader societal welfare. In terms of economics and politics, these and other institutional controls of factions had many desirable features. The Commerce Clause fostered competition among jurisdictions for businesses and residents, giving rise to an optimal mix of taxes and public goods. As Barry Weingast explains, the federalist structure that grew out of the Commerce Clause also allowed state governments to make credible commitments to investors about taxes and regulations in the long term, attracting fixed capital investments to the state. Similarly, the Contract Clause prevented state legislatures from altering the terms of contracts, particularly debt contracts, ex

But these clauses also directly affected the provision of public health, for good and bad. At times, the Commerce Clause obstructed the development of a coherent and rational system of quarantines to combat yellow fever, but the federalist approach it fostered also gave rise to highly effective local programs involving sanitation, which, while they did not eradicate or control yellow fever in any way, had broader public health benefits. In terms of smallpox, the Commerce Clause and the American federalist system gave rise to jurisdictional sorting that allowed anti-vaccinationists to agglomerate in small communities and thereby undermine the goal of universal vaccination in the United States (see ).

Similarly, the Contract Clause and various statutory provisions helped to promote the market for municipal debt in the United States, making it possible for cities to underwrite the construction of large and expensive public water systems. This achievement was significant on two levels. First, investments in public water systems, when taken in the aggregate, were among the largest, and might even have been the largest, public investments in American history. Second, investments in water systems had a larger impact on human mortality than any other public health initiative. About 60 percent of the unprecedented decline in human mortality observed during the late nineteenth and early twentieth century can be attributed to improvements in public water supplies.

In The Pox of Liberty I have also tried to highlight the importance of ideas and how ideas about politics, economics, and science interacted to shape the American disease environment. This component of the narrative is more dynamic than the institutional component. In this ideological component, I describe how the American commitment to commerce and the rise of the germ theory of disease transformed the public health system in the United States, moving it away from one based on volunteerism and private action at the municipal level to one that was more national in scope and involved much more state intervention. Of particular importance is the way the American quest for trade both gave rise to large port cities that were vulnerable to diseases like yellow fever, and fostered a stronger and more imperialist state that helped eradicate yellow fever once and for all. Ironically, the federal government was more successful and aggressive in its efforts to control yellow fever abroad than it had been at home. For its part, the rise of the germ theory of disease had its largest impact on the structure of municipal government, inspiring a wide range of public health programs and fostering growth in the both the size and scope of municipal governments, particularly with regard to public water and sewer systems.