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by William Easterly

  On the plus side, it was the West that solved the scientific problem of what caused AIDS, making prevention efforts possible. Unfortunately, this knowledge did not translate into effective prevention in Africa.

  The World Bank advertises that it is now the “world’s single largest funder of AIDS programs” (the same claim is made by the World Health Organization and by the U.S. Agency for International Development). The World Bank doesn’t mention that it did a total of one project dedicated to AIDS before 1993 (an eight-million-dollar loan to Mobutu in Zaire in 1988). The World Bank today endorses the WHO calculation that Africa needs one billion dollars a year in AIDS-prevention spending. Yet over the entire period 1988–99, the World Bank spent fifteen million dollars a year on all AIDS projects in Africa. In 1992, a World Bank study noted that the Bank “has done little to initiate prevention in countries in which the risk of spread is high.”

  Why did the West not act more vigorously early on in the AIDS crisis? Was it because people didn’t know how bad the crisis would become, because action was ineffective, or simply because it took millions of deaths to make it a headline issue worth responding to?

  The defense that the West didn’t know is not credible. As long ago as 1986, AIDS in Africa was attracting international attention. On October 27, 1986, an article in the Times of London said: “A catastrophic epidemic of AIDS is sweeping across Africa…. the disease has already infected several millions of Africans, posing colossal health problems to more than 20 countries…. ‘Aids has become a major health threat to all Africans and prevention and control of infection…must become an immediate public health priority for all African countries,’ says report published in a leading American scientific journal.”

  Signs of the coming epidemic appeared even earlier. A sample of prostitutes in Butare, Rwanda, in 1983 found that 75 percent were infected. A later study by the group that reported this statistic dated the general awareness that Central Africa was at risk for the spread of AIDS back to 1983 as well.2

  The World Bank did its first AIDS strategy report in 1988. The report said the crisis was urgent. It presciently detected “an environment highly conducive to the spread of HIV” in many African countries. It noted that the epidemic was far from reaching its full potential and that “the AIDS epidemic in Africa is an emergency situation and appropriate action must be undertaken now.3 Yet the effort at the time was underwhelming: the World Bank made a grant of one million dollars to the World Health Organization (WHO) in the 1988/1989 fiscal year to fight AIDS.

  A 1992 World Bank retrospective on the 1988 strategy damns it with faint praise: “In view of the 1988 decision to deal with AIDS using existing resource levels and the small PHN [Population, Health, and Nutrition] staff that has had to handle a steadily increasing work program, we conclude that the agenda in the 1988 Strategy Paper has been reasonably well implemented.4

  The World Bank’s 1993 World Development Report, whose theme was health, notes that “At present, most national AIDS programs are inadequate, despite international attention and the significant effort by WHO to help design and implement plans for controlling AIDS.” Translation: it’s the WHO’s fault.

  An article in 1991 in the World Bank/IMF quarterly magazine predicted that thirty million people would be infected worldwide by the year 2000 if nothing was done.5 The actual figure would turn out to be forty million, but the point is: more than a decade ago many knew that a catastrophic epidemic was under way.

  The 1992 World Bank study, while noting the lack of progress, did sound the obligatory refrain that progress was under way, not least because “countries have been informed of the Bank’s increasing attention to AIDS.”

  The World Bank itself was directing the tiny flows of AIDS financing to “currently affected countries,” while “little has been done by the Bank to prevent AIDS in less affected countries with a high potential for spread.6 The 1992 report closed with the curious admonition that “AIDS should not be allowed to dominate the Bank’s agenda on population, health, and nutrition issues in Africa.” Raising this issue early in the epidemic is strange, when an ounce of prevention is worth a pound of cure. Now AIDS work has crowded out treatment of other equally lethal threats to Africans because its spread was not averted. The best way to have kept AIDS from “dominating the Bank’s agenda” was to have prevented its spread.

  Perhaps we can better understand the aid community’s difficulties on prevention if we realize that prevention was not very visible to the rich-country public. Although insiders knew that a horrific AIDS crisis was brewing in Africa in the late 1980s and early 1990s, this attracted little attention from Western media or politicians. Part of the problem was probably that aid agencies didn’t know what to do to address the crisis, but the above examples show little evidence that they were searching for answers. Only after a truly massive number of people were infected with HIV did AIDS gain the sufficient level of visibility for action.

  Not Following Your Own Advice

  By 1998, the World Bank had done ten stand-alone AIDS projects. Researcher Julia Dayton was hired by the Bank to analyze its programs.7

  Dayton found that only half of the fifty-one World Bank projects with AIDS components promoted condom use or financed condom purchases. To understand this omission, consider another Dayton finding: almost none of the fifty-one projects did any economic analysis of what an effective AIDS interventions was.

  Dayton also found that World Bank country teams were missing in action on AIDS. AIDS was already reaching epidemic levels in Côte d’Ivoire, Haiti, Kenya, and Zambia in the 1990s. The World Bank’s Country Assistance Strategy Documents in the 1990s for those countries did not describe HIV prevalence or transmission, recommend STD-or HIV/AIDS-prevention or care, or in fact analyze HIV/AIDS at all. Ironically for aid agencies that often are trying to do everything, “everything” sometimes leaves out some high priorities.

  Day of Judgment

  Shortly after Dayton’s report was issued, the World Bank produced another AIDS report. The World Bank Africa vice-president wrote in the introduction to this 2000 report that “AIDS is completely preventable.” He gave a prediction that “those who look back on this era will judge our institution in large measure by whether we recognized this wildfire that is raging across Africa for the development threat that it is, and did our utmost to put it out. They will be right to do so.8 He could have spared us the use of the future tense.

  The World Bank did produce a Monitoring and Evaluation Operations Manual, prepared jointly by UNAIDS and the World Bank.9 The manual sensibly warns that “the more complex an M&E system, the more likely it is to fail.” It then spends fifty-two pages laying out its extremely complex M&E system. This includes the ten-step M&E program (step 3: “NAC [National AIDS Councils] and stakeholders engage in an intensive participatory process to build ownership and buy-in, particularly for the overall M&E system and programme monitoring”). There is also the list of thirty-four indicators (none of which involves monitoring “core transmitters”), the nineteen-point terms of reference for the M&E consultant to the NAC, and the “summary terms of reference for specialized programme activity monitoring entity.” The accepted scientific standard for any program evaluation, the randomized controlled trial, did not make it into the manual.

  The Kitty Genovese Effect

  Winston Moseley killed Kitty Genovese, a twenty-eight-year-old bar manager, in Queens, New York, in 1964. Her murder is the first news story I remember from my childhood. As Moseley first stabbed Kitty, neighbors heard her screams but didn’t call the police. Moseley drove away and then came back and stabbed her some more, till she died. Police later identified thirty-eight neighbors who saw or heard part of the attack. The eyewitnesses’ failure to call police became a symbol of the callousness of urban America. I think my mother showed me the newspaper to illustrate the wickedness of big-city folks.

  The last thing I want to do is defend such bad Samaritans, but economists point out that the call
ousness of each individual was not as great as their group behavior suggests. All the neighbors agreed that saving Kitty’s life would have been worthwhile. Outraged commentators pointed out that only one out of those thirty-eight people had to call the police, but that was exactly the problem. Calling the police would have had some cost to the individual, who may later have had to testify and may have feared retribution from the associates of the killer. Each of the thirty-eight people might have been willing to bear this cost to save Kitty’s life, but preferred that someone else make the call. With so many witnesses to the scene, each person calculated a high probability that someone else would make the call and save Kitty. Therefore, each person did nothing. If there had been only one witness, and if that person had known he was the only witness, he would have been more likely to call the police.

  The Kitty Genovese effect is another plausible example of the problem of collective responsibility I mention in chapter 5, which leads to bureaucratic inaction. Each development agency is one among many responsible for solving crises in the poor countries. Each agency may altruistically care about the poor. Suppose that action by one agency will be enough to solve a problem, and all agencies will share in the glory of the triumph; it is difficult to tell which agency’s effort made the difference. If effort is costly and diverts resources away from other organizational goals, each agency will prefer that some other agency make the effort. The more agencies that could act, the less likely that action will occur.

  The Genovese effect can also operate within aid bureaucracies. Each department might wish that results happen, but would prefer that some other department achieve them, with glory for all. Departments then get into the game of shifting responsibility for difficult tasks onto other departments, which drives the leaders of even the most results-oriented agency insane.

  Action does become more likely as the status quo deteriorates due to inaction. The crisis could eventually become big enough to outweigh the option of waiting for someone else to act. In the Kitty Genovese example, a neighbor did eventually call the police. Kitty was dead by then.

  A story like this could help account for the long period of inaction on the AIDS crisis, until the crisis was so severe that finally aid agencies acted.

  Orphans in the Storm

  Mary Banda, about sixty-five, lives in Lusaka, Zambia.10 Five of her eight children have died from AIDS. In Zambia, adult children usually care for their aged parents. AIDS reversed the equation for Mary Banda. Instead of her children caring for her, she is caring for eight orphaned grandchildren, ranging in age from six to twenty.

  Mbuya (Grandmother) Banda doesn’t get much help from her three surviving children. One of her children is in South Africa, and Mbuya hasn’t heard from her. Her youngest daughter is unmarried and unemployed. Her remaining daughter is married, but does not work; her husband can only sporadically find work. She comes around with a bag of mealie meal (cornmeal) every now and then.

  The biggest problem is finding food for the orphans. Mrs. Banda sells groundnuts by the road, and grows a little maize, sweet potato, and greens. It is never quite enough. Only two of the children are in school, where they are sometimes refused entry because they lack fees, shoes, and uniforms.

  When her children became sick from AIDS, she tried traditional healers as well as the hospital. Mary Banda believes her children died from witchcraft—a sign of the need to adjust to local conditions with prevention messages. Her four deceased daughters were businesswomen buying secondhand clothes in Lusaka and exchanging them for groundnuts in the villages, and then reselling the groundnuts in Lusaka. She believes villagers jealous of their success bewitched her daughters through their feet. She blames her son’s death on witchcraft from jealous rivals after his work promoted him. She wishes her children had seen a witchdoctor to get preventive medicine to put on their feet.

  Discussion of African beliefs in witchcraft is taboo in aid agencies, as nobody wants to reinforce ill-informed stereotypes. Unfortunately, political correctness gets in the way of making policy, as conventional public health approaches may not work if people do believe that witchcraft causes illness and turn to traditional healers. Americans and Europeans also believed in witches when they were at similar levels of income as Africa (and many Americans still do today; hence the spiritualism section at the Barnes & Noble bookstore in Greenwich Village—one of the intellectual capitals of the United States—is three times the size of the science section). Moreover, many American evangelicals believe divine intervention can cure illness.

  Beliefs in invisible malign forces in Africa are not so surprising when a virus visible only to scientists is killing previously healthy young people. Princeton political scientist and ethnographer Adam Ashforth documented the widespread belief in Soweto, South Africa, that witchcraft causes many symptoms of illness, including symptoms similar to AIDS.11 AIDS-prevention efforts would do much better to work with traditional healers on fighting HIV transmission than to ignore beliefs in witchcraft because of political sensitivities.

  Mrs. Banda speaks for her generation of Mbuyas: “I’m an old woman who’s suffering. When I was young, I never thought such cruel things could happen. When I think about it, I pray and cry, but I don’t like to cry because it’ll upset the children.”

  At least Mrs. Banda’s grandchildren have her to care for them. A group even more unlucky is Lusaka’s growing population of street children. AIDS orphans with no one to care for them are on the street. The manager of a shelter for abandoned kids, Rodgers Mwewa, noticed the increase in orphaned children coming into Lusaka. The traditional extended-family system of caring for children is breaking down because too many of its adult members are dead. “HIV is destroying families and family bonds,” says Mwewa.12

  The street children don’t live long: cars frequently hit them, they get into fights, and they resort to petty crime, drugs, or sniffing glue. They are beaten up by the police. Worst of all, the children sell themselves for sex, and thus sooner or later acquire the HIV virus that killed their parents.

  Less anecdotal evidence confirms that orphans in Africa face a rough road. The less orphans can rely on family, the worse off they are. Princeton University scholars Anne Case, Christine Paxson, and Joseph Ableidinger found in a study of orphans in ten African countries that orphans who live with unrelated adults get less schooling than orphans who live with non-parental relatives, who themselves get less schooling than children living with their parents. These effects show up even as discrimination within the household. For example, an orphan living with her aunt and uncle typically gets less schooling than her cousin, the aunt and uncle’s child.13

  Africa’s AIDS crisis is leaving a generation of undereducated, undernourished, underparented orphans who will soon be adults. As if Africa’s development crisis weren’t bad enough for the current generation, the orphans of AIDS complicate development even more.

  Treating the Sick

  Now that twenty-nine million people in Africa are HIV-positive, compassion would call for treating the sick, right? Yet pity is not always a reliable guide to action. By a tragic irony, compassion is driving the fight against AIDS in Africa in a direction that may cost more lives than it saves. It is political suicide in rich countries to question AIDS treatment. Too bad—what should matter is what helps the poor the most, not what sells politically in rich countries. This political pressure led Planners to fixate on the goal of treatment even when the costs were so prohibitive that it diverted money from cheaper actions that Searchers had found to save many more lives.

  The Western aid community is now installing a gold-plated barn door after the horse has been stolen. Foreign aid programs are now starting to finance the “triple-drug cocktail” known as highly active antiretroviral therapy (HAART), which has dramatically lowered AIDS mortality in the West. All of the actors described earlier signed on to financing AIDS treatment. The UN General Assembly Special Session passed a resolution calling for AIDS treatment. This used to be impossible
for low-income African AIDS patients, because of high drug prices (ten thousand dollars a year per patient). However, competition from a growing number of generic HIV/AIDS drugs has cut prices, which are now as low as $304 per year per patient.14 This caused leaders of international aid agencies, such as former WHO director-general Grö Harlem Brundtland, to ask, “Does anyone deserve to be sentenced to certain death because she or he cannot access care that costs less than two dollars a day?” The WHO started a “3 by 5” campaign to get three million HIV-positive patients on antiretroviral therapy by the end of 2005.

  Saving lives is not so simple. First of all, the focus on drug prices under-states the expense and difficulty of treatment. Three hundred and four dollars is just the price of the first-line therapy drugs per year. The population first needs to be tested to see who is HIV-positive. Patients need to have their viral load tested to see if they should start taking drugs and, after taking them, if the drugs are working to decrease the viral load. The drugs are toxic, with potentially severe side effects. Health workers need to adjust the combination of drugs when side effects are too extreme. Patients need counseling and monitoring to make sure they are taking the medicine (if there is less than full adherence to treatment, the virus builds up resistance to the drugs). Patients also need treatment for the opportunistic infections that afflict AIDS sufferers. So treatment is more expensive than just the cost of the drugs. The World Health Organization is working with a figure of $1,500 per year per patient for delivering treatment to prolong the life of an AIDS patient by one year. Even if the WHO can drive down the price of the drugs further, the cost per year would still be $1,200. Other experts use similar fig-ures.15 But is even this number too high to justify giving a person another year of life?

  The advocates for treatment stress the universal human right for HIV-positive patients to have access to life-saving health care, no matter what the cost. This is a great ideal, but a utopian one. There are also other ideals—first of all, prevention of the further spread of AIDS. And what about the universal human right for health care for other killer diseases, freedom from starvation, and access to clean water? Who chose the human right of universal treatment of AIDS over the other human rights? A non-utopian approach would make the tough choices to spend foreign aid resources in a way that reached the most people with their most urgent needs.