The End of Poverty Part 7

THE END OF POVERTY

HOW WE CAN MAKE IT HAPPEN IN OUR LIFE TIME

JEFFREY SACHS

PENGUIN BOOKS              2005

PART VII

Chapter 10: The Voiceless Dying: Africa and Disease (Cont.)

The malaria mystery

I had a lot to learn about disease and public health. It took me a while to understand the dire state of affairs. I still remember asking, “What do you mean they are not going to doctors? They have AIDS but they are not seeing doctors? Their children suffer from malaria-induced anemia but are not treated? How can this be?” “You know, there are treatments for AIDS and malaria, “ I spluttered. “What do you mean, there are no medicines here? What do you mean, there’s no treatment program? What do you mean, USAID is doing nothing? What do you mean that the World Bank hasn’t had an AIDS or malaria program in this country for years?” These were basic questions that I had never asked before coming to Africa. Strangely, neither had other economists, including those leading the IMF and World Bank missions to Africa.

• Malaria is utterly treatable, yet, incredibly, it still claims up to 3 million lives a year, mostly young children, about 90% of whom live in Africa.
• Low cost treatments exist, but they do not reach the poor.
• The first finding I tried to establish was whether malaria and poverty were intertwined because poor countries lacked the means to fight malaria, or also because malaria contributes to extreme poverty. The evidence suggests both directions of causation.
• It is worth remembering how malaria and yellow fever delayed the construction of the Panama Canal for more than thirty years. Malaria to this day can stop a good investment project in its tracks, whether a new mine, farm, or tourist site.
• When children die in large numbers, parents overcompensate and have more children, with devastating results. Too poor to invest in the education of all of their children, the family might educate just one child, usually the elder son.
• If children in malarious regions manage to survive, they enter adulthood without the proper education they need to succeed.
• Malaria in the United States, and indeed in every other place in the world outside Africa, was easier to control. Africa had it the worst, not because of poor governance and lack of public health services, but because of a unique disease environment.
• Malaria had coevolved with humans in Africa, and the result was a special intensity of transmission unequaled in any other part of the world.
• Some types of mosquito prefer to bite people, whereas others feed off cattle. Transmitting malaria requires two successive human bites: the first for the mosquito to ingest the parasite and the second for the mosquito to infect another person.
• In India the predominant type of anopheles tends to bite humans about one third of the time, and cattle the rest. Africa has another predominating mosquito type which prefers human biting nearly 100% of the time.
• The force of transmission of malaria in Africa is roughly nine times that of India because of the difference of mosquito species.
• Africa is really unlucky when it comes to malaria: high temperatures, plenty of breeding sites, and mosquitoes that prefer humans to cattle.
• Household spraying, insecticide-treated bed nets, and antimalarial medicines all work in Africa.
• No children need to die, and none will if they have access to all of the modern tools of disease prevention and treatment.
• Yet malaria sets the perfect trap: it impoverishes a country, making it too expensive to prevent and treat disease. Thus malaria continues and poverty deepens in a truly vicious circle.
• I fully expected to find that whatever could be done to fight malaria was already being done. Surely, I thought, the world community would not simply be standing by while millions of children were dying each year.
• The level of rich-country help to Africa to fight malaria was minimal, in the tens of millions of dollars per year when $2 to $3 billion was needed.

I was shocked. I started to scour the World Bank and USAID Web sites and project descriptions. Surely we had overlooked a massive effort to help Africa fight the disease. But no, the original calculations were correct. Malaria was not on the policy radar screen. The IMF and World Bank were apparently too busy arguing for budget cuts and privatization of sugar mills to have much time left to deal with malaria.

Africa’s AIDS cataclysm

• The same three questions applied for AIDS as for malaria. What does the disease do to economic growth and poverty? What accounts for Africa’s special circumstances? And what must be done.
• The answers are similar, but they have one important difference: as of today there is no solid explanation for why Africa’s AIDS prevalence is at least an order of magnitude higher than anywhere else in the world.
• Perhaps the sexual networking is different in Africa. The truth is that nobody is sure. The only certainty is that HIV/AIDS is an unmitigated tragedy and a development disaster throughout Africa, especially in the hardest hit regions of eastern and southern Africa.

As for the economic costs of the disease, these certainly rival or exceed malaria’s in the disaster at hand. Africa is losing its teachers and doctors, its civil servants and farmers, its mothers and fathers. There are already more than ten million orphaned children. Business costs have soared because of disarray from massive medical costs for workers, relentless absenteeism, and an avalanche of worker deaths. Foreign investors are deterred from stepping into Africa’s AIDS morass. And millions of households are battling the illness of the head of household., resulting in an incredible toll in time and expense, to say nothing of the emotional trauma for the family.

• By the late 1990s, AIDS in the rich counties was being treated, with growing success. Individuals infected with HIV now had hope.

Certainly, I thought, the same must be happening in the low-income world. With all the worldwide attention on AIDS, and all the hand ringing and speeches, surely the donor world was gearing up to help the impoverished world to fight this terrifying epidemic. But once again my presumptions were wrong.

• Could it really be true that the world was giving just $70 million to all Africa to fight AIDS?

Over and over again I saw the difference between spin and reality in how the world community faced AIDS and malaria. At one point, for example, an IMF official published a letter in the Financial Times noting that health and education spending in poor countries with IMF programs was actually up 2.8% between1985 and 1996. The fact is, however, that although the IMF official was correct in a strictly technical sense, health spending was disastrously, indeed shockingly, low in African countries with IMF programs. In most cases, public health spending in 1996 was below $10 per person, so the increase had been from almost nothing to almost nothing. I was initially amazed that the IMF would play such tricks with the public, but I came to realize that the fund had no special feel for these numbers. The IMF management and staff know very little about public health, and traditionally they pay almost no attention to whether health spending in their client countries is $10 or $100 or $1,000 or more per person (as it for the rich countries that dominate the Executive Board of the institution).

In the late 1990s, in the wake of my public spats with the IMF over their mismanagement of the 1997-98 East Asian financial crisis, I went on the warpath with the international financial community over AIDS and malaria. I called for an end to the international community’s gross negligence regarding the diseases ravaging Africa. I complained that the IMF and World Bank had been in Africa for decades, but had remained blind to the most basic realities there, and to the growing human and economic catastrophe.

At about this time I received a call from Dr. Gro Harlem Brundtland, who had recently been appointed director general of the World Health Organization. Brundtland was former prime minister of Norway and, without doubt, one of the world’s most skilled political leaders. In the mid-1980s she chaired the famous Brundtland Commission, which had launched the concept of sustainable development. She said to me, “If you want to get someone’s attention about the health crises in Africa, ‘show them the money.’ Help them to understand the economic costs of the disease pandemics, as well as the economics of disease control. Above all, propose practical solutions based on rigorous emphasis on economic costs and benefits.”

Brundtland suggested that I chair a commission of macroeconomists and public health specialists to do just that. The WHO Commission on Macroeconomics and Health (CMH) was born. I chaired the commission for two years, from the start of 2000 to the end of 2001. In December 2001, the CMH published its report, Investing in Health for Economic Development. This was the work of 18 commissioners, including Harold Varmus, Nobel laureate and former director of the National Institutes of Health; Supachai Panitchpakdi, who would go on to lead the World Trade Organization; Robert Fogel, the Nobel laureate economic historian at the University of Chicago; and Manmohan Singh, the former finance minister and future prime minister of India. In addition to this stellar commission, we drew upon six task forces that included more than a hundred specialists from around the world. The commission and task forces had senior representation of the IMF, the World Bank, and several donor agencies.

The commission gave me a wonderful opportunity to test my favorite hypothesis about collective rationality, which is that if you put people of strongly opposing views in a room together, and infuse their discussion with data, background studies, and unhurried time for debate, it is possible to bridge seemingly irreconcilable positions among its members of the group. I have come to call this process analytical deliberation. It works. The commission was deeply divided at the start about who was “to blame” for Africa’s roiling disease crisis: Africans for their mismanagement, the pharmaceutical industry for its greed, the rich world for its malign neglect. Did Africa need more aid, or just better use of those resources that it had at hand? Could anti-AIDS drug treatment be applied in Africa? On these and a dozen other issues, the first day of the two year process was contentious, to say the least. On the last day, when the report was issued, we had reached a consensus that extended not only to the 18 commissioners and hundreds or so experts in the working groups, but also to major representatives of the pharmaceutical industry and the NGO community. We had worked diligently and assiduously to bring forward evidence and a consensus on three basic issues:

First, is disease a cause of poverty, a result of poverty, or both? The commission concluded that causation runs strongly in both directions. Poor health causes poverty and poverty contributes to poor health.

Second, why do poor countries have a life expectancy several decades shorter than rich countries? Why, especially, is Africa’s life expectancy, at 47 years in 2000, more than three decades less than the 78 years of the rich countries? The commission identified eight areas that accounted for the vast proportion of the gap in disease burden: AIDS, malaria, TB, diarrheal disease, acute respiratory infection, vaccine-preventable disease, nutritional deficiencies, and unsafe childbirth.

Third, how much should the rich world help the poor world to invest in health? The commission calculated that donor aid ought to rise from around $6 billion per year to $27 billion per year (by 2007). With the combined GNP of the donor countries equal to around $25 trillion dollars as of 2001, the commission was advocating an annual investment of around one thousandth of the rich-world income. The commission showed, on the best epidemiological evidence, that such an investment could avert eight million deaths per year.

The report of the Commission on Macroeconomics and Health had quite a notable reception. Reports come and go. This one, I think it is fair to say, came and stayed. It made the important point that we, as a generation, can do something dramatic to improve our world. The report found a wide audience, in part, because it was based on a broad and surprising consensus. It was launched with the kind of pizzazz that it deserved, with Brundtland; the UK Secretary of State for International Development Clare Short; Ray Gilmarin, the CEO of Merck; and Bono as enthusiastic supporters.

Birth of the Global Fund to Fight AIDS, TB, and Malaria

SOME LESSONS LEARNED

A decade of intensive work in Africa has added to my determination to fight against the prejudices and misperceptions that leave hundreds of millions of impoverished people stranded in unnecessary suffering. Africa gets a bad rap as the “corrupt continent.” Even when such sentiments are not racist in intent, they survive in our societies as conventional wisdom because of existing widespread racism. Many African governments are desperately trying to do the right thing, but they face enormous obstacles of poverty, disease, ecological crisis, and geopolitical neglect or worse.

Since the issuance of the Macroeconomics and Health Report and the launch of the Global Fund, I have turned my own attention in Africa to issues beyond public health. Africa needs solutions not only for disease control, but also for chronic hunger, rural isolation, and growing environmental degradation, often the result of still-booming populations. As in the case of disease, there are special reasons why Africa is particularly hard pressed in each of these areas. In other words, geography has conspired with economics to give Africa a particularly weak hand. I have noted that Africa lacks navigable rivers with access to the ocean for easy transport and trade. Moreover, much of Africa’s population lives in the interior of the continent rather than at the coast. Indeed, sub-Saharan Africa’s highest population densities are in the highland regions, such as Ethiopia and Rwanda, because rainfall reliability and soils tend to be a bit better there than in the interior lowlands and coast. Yet these highland populations are isolated from the international divisions of labor. In general, Africa lacks irrigation, and more than 90% of the food crops are rain fed. Rainfall tends to be highly variable in the subhumid savannah and the arid Sahel near the Sahara. Farmers lack access to roads, markets, and fertilizers. Soils have been long depleted of nutrients as the result of repeated harvests without benefit of chemical or organic nutrient inputs. Without transport, telecommunications, clinics, and fertilizers, the hunger-disease-poverty nexus has only deepened.

The combination of Africa’s adverse geography and its extreme poverty creates the worst poverty trap in the world. Yet the situation in Africa is not hopeless. Far from it. Just as my malaria-expert colleagues taught me about bed nets, indoor spraying, and effective antimalarial medicines, and just as my HIV/AIDS-knowledgeable colleagues taught me what can be accomplished through effective prevention programs linked to access to anti-AIDS drugs, so my colleagues in tropical agriculture, rural electrification, road building, and safe water and sanitation began to teach me what could be done in these other areas of vital concern.

Africa’s problems, I have come to understand, are especially difficult but still solvable with practical and proven technologies. Diseases can be controlled, crop yields can be sharply increased, and basic infrastucture such as paved roads and electricity can be extended to the villages. A combination of investments well attuned to local needs and conditions can enable African economies to break out of the poverty trap. These interventions need to be applied systematically, diligently, and jointly, since they strongly reinforce one another. With focused attention by African countries and the international community, Africa could soon have its own Green Revolution, and achieve a takeoff in rural-led growth, thereby sparing the coming generation of Africans the continued miseries of drought-induced famine. Sooner that I expected, I received an important new opportunity to put these ideas into practice.

Chapter 11: The Millennium, 9/11, and the United Nations