Published by EH.Net (July 2016)

Werner Troesken, The Pox of Liberty: How the Constitution Left Americans Rich, Free, and Prone to Infection. Chicago: University of Chicago Press, 2015. x + 237 pp. $40 (cloth), ISBN: 978-0-226-92217-1.

Reviewed for EH.Net by Carl Kitchens, Department of Economics, Florida State University.

Recently, the economic growth literature has widely debated the relationship between the disease environment and economic growth. Economists such as Jeffrey Sachs have noted that certain regions of the world are poor because of their disease environment, and will remain poor so as long as disease persists.  Other scholars, such as Daron Acemoglu, Simon Johnson, and James Robinson (AJR) argue that the quality of institutions may be a more important determinate of economic growth, noting the decline of many European colonies after European nations gained control from indigenous populations in the New World. Enter Werner Troesken (Professor of Economics, University of Pittsburgh) and his new book, The Pox of Liberty. Troesken takes a different approach from both Sachs and AJR. Early on, Troesken asks an important question given the relative quality of institutions in the United States: “How and why did the United States — the richest, most technologically advanced democracy in the world at the time — lag behind poorer and often less benevolent societies in eradicating smallpox, as well as several other infectious diseases?” (p. 3). Throughout the remainder of the book, Troesken answers this question by appealing to the American system itself. In a single word, the reason the America historically had such a high disease rate: liberty.

The fact the American political system values individual liberty and allows the public to elect officials that share their beliefs, combined with a strong history of individual and states’ rights allowed local preferences and, in some cases, the voices of a few to prevent compulsory vaccination and deter certain public health investments. While this book’s focus is on the eradication of smallpox and typhoid from the late eighteenth to the early twentieth century, its framework is useful in understanding contemporary public health debates and policy.  Recently, scientific evidence has debunked the potential link between autism and vaccination, yet there is still a strong anti-vaccine movement among parents of newborns. Likewise, the HPV vaccine is highly effective in reducing cervical cancer later in life, yet vaccination rates remain relatively low due to a resistance to discussing reproductive health with young daughters. Understanding that the American system empowers these voices should shed light on the persistence of disease in the United States.

The meat of the book begins by discussing the role of urbanization on public health policy. Initially, small, tight knit townships were able to address many of the externalities associated with public health problems. However, as commerce and industry expanded, creating larger, more diverse population centers, social pressure and social norms became a less effective means to internalize externalities. Combined with the development of germ theory, which suggested larger investments in public health, the scope for government action increased.

In Chapter 3, the book transitions to discuss the rise of interest groups and how they were able to influence policy for all. The chapter highlights a particularly ugly incident from American history. In 1900, white citizens in San Francisco required that individuals of Chinese decent be vaccinated to prevent plague (by force if necessary). While the rule was overturned in federal court under the equal protection clause of the Fourteenth Amendment, this incident highlighted the power of the majority and developing factions. Chapter 3 also begins to outline the importance of states being granted the power to grant monopolies, which provide mechanisms to credibly commit to certain contracts. This ability eventually became very important in terms of the provision of running water and sewerage.

Chapter 4 is one of the star chapters of the book. After outlining the importance of certain clauses within the constitution in early chapters, Chapter 4 is devoted to demonstrating how disease rates (smallpox) varied across a wide swath of geography and political environments. In England, Sweden, and among Italian soldiers, smallpox rates were markedly lower if one were vaccinated. In the United States, smallpox persisted. Yet the United States had the capability to eradicate smallpox and did so in its territorial possessions. After acquiring Cuba, Puerto Rico, and the Philippines in the Spanish American War, the U.S. Army eradicated smallpox in five, five, and fifteen years respectively, despite the hostile climate in each location. This suggestive data, combined with narrative describing a series of court battles regarding compulsory vaccination in Massachusetts, highlights the role that the institutional structure played in the persistence of disease in the United States, while the military remained relatively unconstrained in other environments. These types of constraints arise again in Chapter 6 when Troesken discusses policy to combat yellow fever, as the military was highly effective in reducing yellow fever abroad while it persisted at home.

Chapter 5 is devoted to the rise of large investments in water and sewage infrastructure. The ability of local, state, and the federal government to credibly commit to its debt obligations allowed large scale investments to be made to provide clean water. These projects were the largest infrastructure investments made to date, and have had profound effects on human health. Simple procedures, such as filtration, reduced the prevalence of typhoid, particularly for blacks, and contributed to the overall decline in death rates, which helped support large urban populations.

After finishing the book, one is left with the following impression: The institutions, which provide individuals the incentives to trade and produce have also hindered higher levels of government from internalizing public health externalities. Thus, the United States has been able to amass significant wealth and income due to individual effort, yet has continued to battle certain diseases longer than other nations with a stronger central government. At the same time, the government’s desire to pay its debts has also facilitated large, long term investments to improve water infrastructure. This nuanced study has helped fill a gap in the existing literature by highlighting that the institutions and disease environment are part of an endogenous relationship between the two.

Carl Kitchens’ research studies the impacts of large scale infrastructure investments on a variety of outcomes. Most recently, his work has been concentrated on investments in electricity.  He is the author (with Taylor Jaworski) of “Ownership, Technology, and the Provision of Residential Electricity” (forthcoming in Explorations in Economic History) and is currently working on “National Policies for Regional Development: Evidence from Appalachian Highways” (with Taylor Jaworski).

Copyright (c) 2016 by EH.Net. All rights reserved. This work may be copied for non-profit educational uses if proper credit is given to the author and the list. For other permission, please contact the EH.Net Administrator ( Published by EH.Net (July 2016). All EH.Net reviews are archived at