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Global Health Priorities
I've been doing a fair amount of reading on international development programs focusing on global health issues - primarily on AIDS, Malaria, and Tuberculosis prevention and treatment. But what is striking to me is that though AIDS is indeed pandemic, it currently affects 33 million people. The amount of money being poured into its prevention over the next ten years could be up to 100 USDollars per person afflicted, while the number of people being reached by the 30 million USDollars spent on communicable water diseases is minimal. Those diseases, what the World Health Organization has termed Neglected Tropical Diseases (NTDs), which are things like Buruli ulcer, cholera, cysticercosis, dracunculiasis (guinea-worm disease), foodborne trematode infections (such as fascioliasis), hydatidosis, leishmaniasis, lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminthiasis, trachoma and trypanosomiasis, affect over ONE BILLION people worldwide. It's really staggering stuff - and to think that many experts believe those diseases are fairly easily treated and/or prevented if the proper steps are taken.
Anyway, this article put some of these issues specifically related to the international response, into a bit more clear of perspective and I found it quite interesting.
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| January 1, 2008 Op-Ed Contributor Putting a Plague in Perspective By DANIEL HALPERIN Cambridge, Mass. ALTHOUGH the United Nations recently lowered its global H.I.V. estimates, as many as 33 million people worldwide are still living with the AIDS virus. This pandemic requires continued attention; preventing further deaths and orphans remains imperative. But the well-meaning promises of some presidential candidates to outdo even President Bush�s proposal to nearly double American foreign assistance to fight AIDS strike me, an H.I.V.-AIDS specialist for 15 years, as missing the mark. Some have criticized Mr. Bush for requesting �only� $30 billion for the next five years for AIDS and related problems, with the leading Democratic candidates having pledged to commit at least $50 billion if they are elected. Yet even the current $15 billion in spending represents an unprecedented amount of money aimed mainly at a single disease. Meanwhile, many other public health needs in developing countries are being ignored. The fact is, spending $50 billion or more on foreign health assistance does make sense, but only if it is not limited to H.I.V.-AIDS programs. Last year, for instance, as the United States spent almost $3 billion on AIDS programs in Africa, it invested only about $30 million in traditional safe-water projects. This nearly 100-to-1 imbalance is disastrously inequitable � especially considering that in Africa H.I.V. tends to be most prevalent in the relatively wealthiest and most developed countries. Most African nations have stable adult H.I.V. rates of 3 percent or less. Many millions of African children and adults die of malnutrition, pneumonia, motor vehicle accidents and other largely preventable, if not headline-grabbing, conditions. One-fifth of all global deaths from diarrhea occur in just three African countries � Congo, Ethiopia and Nigeria � that have relatively low H.I.V. prevalence. Yet this condition, which is not particularly difficult to cure or prevent, gets scant attention from the donors that invest nearly $1 billion annually on AIDS programs in those countries. I was struck by this discrepancy between Western donors� priorities and the real needs of Africans last month, during my most recent trip to Africa. In Senegal, H.I.V. rates remain under 1 percent in adults, partly due to that country�s early adoption of enlightened policies toward prostitution and other risky practices, in addition to universal male circumcision, which limits the heterosexual spread of H.I.V. Rates of tuberculosis, now another favored disease of international donors, are also relatively low in Senegal, and I learned that even malaria, the donors� third major concern, is not quite as rampant as was assumed, with new testing finding that many fevers aren�t actually caused by the disease. Meanwhile, the stench of sewage permeates the crowded outskirts of Dakar, Senegal�s capital. There, as in many other parts of West Africa and the developing world, inadequate access to safe water results in devastating diarrheal diseases. Shortages of food and basic health services like vaccinations, prenatal care and family planning contribute to large family size and high child and maternal mortality. Major donors like the President�s Emergency Plan for AIDS Relief, known as Pepfar, and the Global Fund to Fight AIDS, Tuberculosis and Malaria have not directly addressed such basic health issues. The Global Fund�s director, Michel Kazatchkine, has acknowledged, �We are not a global fund that funds local health.� Botswana, which has the world�s most lucrative diamond industry and is the second-wealthiest country per capita in sub-Saharan Africa, is nowhere near as burdened as Senegal with basic public health problems. But as one of a dozen Pepfar �focus� countries in Africa, this year it will receive about $300 million to fight AIDS � in addition to the hundreds of millions already granted by drug companies, private foundations and other donors. While in that sparsely populated country last month, I learned that much of its AIDS money remains unspent, as even its state-of-the-art H.I.V. clinics cannot absorb such a large influx of cash. As the United States Agency for International Development�s H.I.V. prevention adviser in southern Africa in 2005 and 2006, I visited villages in poor countries like Lesotho, where clinics could not afford to stock basic medicines but often maintained an inventory of expensive AIDS drugs and sophisticated monitoring equipment for their H.I.V. patients. H.I.V.-infected children are offered exemplary treatment, while children suffering from much simpler-to-treat diseases are left untreated, sometimes to die. In Africa, there�s another crisis exacerbated by the rigid focus on AIDS: the best health practitioners have abandoned lower-paying positions in family planning, immunization and other basic health areas in order to work for donor-financed H.I.V. programs. The AIDS experience has demonstrated that poor countries can make complex treatments accessible to many people. Regimens that are much simpler to administer than anti-retroviral drugs � like antibiotics for respiratory illnesses, oral rehydration for diarrhea, immunizations and contraception � could also be made widely available. But as there isn�t a �global fund� for safe water, child survival and family planning, countries like Senegal � and even poorer ones � cannot directly tackle their real problems without pegging them to the big three diseases. To their credit, some AIDS advocates are calling for a broader approach to international health programs. Among the presidential candidates, Senator Barack Obama, for example, proposes to go beyond spending for AIDS, tuberculosis and malaria, highlighting the need to also strengthen basic health systems. And recently, Mr. Bush�s plan, along with the Global Fund, has become somewhat more flexible in supporting other health issues linked to H.I.V. � though this will be of little use to people, especially outside the �focus� countries, who are dying of common illnesses like diarrhea. But it is also important, especially for the United States, the world�s largest donor, to re-examine the epidemiological and moral foundations of its global health priorities. With 10 million children and a half million mothers in developing countries dying annually of largely preventable conditions, should we mutiply AIDS spending while giving only a pittance for initiatives like safe-water projects? If one were to ask the people of virtually any African village (outside some 10 countries devastated by AIDS) what their greatest concerns are, the answer would undoubtedly be the less sensational but more ubiquitous ravages of hunger, dirty water and environmental devastation. The real-world needs of Africans struggling to survive should not continue to be subsumed by the favorite causes du jour of well-meaning yet often uninformed Western donors. Daniel Halperin is a senior research scientist at the Harvard School of Public Health. |
That's an interesting topic. More generally, I would say that programs aimed at addressing large-scale national or international problems tend to suffer similar deficiencies. Many of the problems seem to me to stem from the underlying economy between public funding and public perception of benefit.
When a non-government organization collects funding for its initiatives this dynamic tends to be more transparent: the donor receives a benefit of satisfaction from the perception that their donation will help solve a problem, and the organization receives the funding it needs to operate its programs. The principle is the same when a government allocates tax revenue for such a program -- the taxpayer will judge that allocation according to his or her perception of the benefit it will ultimately yield, and thus the political incentive to enact a particular program is proportional to the benefits of that program not as they actually are, but as they are perceived by the public.
Unfortunately, in both cases the source of the funding -- whether the public generally or private donors -- is usually not well-equipped to judge what benefit a program will yield. The article Lesbianosaur posted mentioned that President Bush was criticized for not requesting more funds for AIDS and related problems. This is because the perceived benefit of such funds is high -- the public reads news articles about the damage and loss of life caused by AIDS, and they are able to relate to those problems because they are familiar with the disease both by reputation and by the fact that AIDS has some significant prevalence in western nations as well.
On the other hand, there is little or no perceived benefit for funds targeting many of the food and water-borne parasites which afflict considerable numbers of individuals, particularly in some of the world's poorest regions. Such diseases are largely foreign to the average person, who would most certainly not recognize their names (as they would AIDS) much less be able to identify with the people afflicted by it. Furthermore, the media gives less attention to these diseases -- though that itself is largely because they are less recognizable and therefore less likely to engage consumers of news media. I would note, however, that it is a commendable exception to see the article quoted in this thread published in the "mainstream" media.
It is a problem that will not be easily overcome. It is simply not plausible to think that the general population will any time soon become sufficiently able to judge accurately the "actual" benefit of international health programs. It may be possible to mitigate this by earmarking funding for health problems more generally and allowing more informed decision-makers decide how to allocate the funds. However, this is not without problems of its own, and even if it is accomplished, the bias towards working on "sexier" health problems is present within the system as well.
Changing those priorities will not be easy, not will it occur quickly. But I do believe that it is possible, if we continue to increasingly emphasize the critical evaluation of how such funds are dispersed. It is doubtful that it can ever be "optimal" or even close to it, but getting more effective health benefits to more people is an achievable goal, and one well worth pursuing.
I think Arbiter is right on the money. One of the biggest challenges in international development is indeed donor fatigue. Most organizations are either publicly-funded or rely completely on the goodwill of philanthropists and corporate donors. In either case, whether the money comes from Congress or private grants, there is a lot of pressure for projects to have tangible outcomes, or at least a visible presence. People want to know what their money is going toward.
It's a very valid point that AIDS is simply more recognizable for donors, thereby making donations to AIDS programs more attractive than those going toward preventing the spread of water-borne parasites or something. It's a difficult problem to solve, as most donors want to know precisely what their money is going toward, and don't feel comfortable donating to a program that has a wide, vague mandate.
I'm not going to delve too deeply into this one, but a good read on this topic is Tracy Kidder's "Mountains Beyond Mountains." It's a biography of Paul Farmer, a doctor who has been dealing with issues such as these for a long time. I'm not a huge fan of the man himself, but his work is certainly astounding and many of the issues you've brought forth are discussed quite thoroughly.
Many of those "one billion" people are affected by many more things than what you're layout out here.
One thing they are NOT affected by would be our supply & demand routes.
Living in a tropical country myself, I tend to agree with Arbiter. I'm optimistic about it, however, because as tropical countries become more developed, we can use our resources in order to fight the diseases that we're acquainted with. I know we've done quite a lot to tackle the Chagas disease, among other things.
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