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by William Easterly

  Poor people have many other needs besides AIDS treatment. The total amount of foreign aid for the world’s approximately three billion poor people is only about twenty dollars per person per year. Is the money for AIDS treatment going to be “new money” or will it come from these already scarce funds? President Bush’s 2005 budget proposal increased funding for the American AIDS program (especially treatment), but cut money for child health and other global health priorities by nearly a hundred million dollars (later reversed after protests).16

  Bush’s cut in other health spending was particularly unfortunate when two and a half times as many Africans die from other preventable diseases as die from AIDS. These diseases include measles and other childhood illnesses, respiratory infections, malaria, tuberculosis, diarrhea, and others. Worldwide, in 2002 there were 15.6 million deaths from these causes, as opposed to 2.8 million deaths from AIDS.17

  A well-established public health principle is that you should save lives that are cheap to save before you save lives that are more expensive to save. That way you save many more lives using the scarce funds available. Prevention and treatment of these other diseases cost far less than AIDS treatment.

  Granting life through prevention of AIDS itself costs far less than AIDS treatment. A years’ supply of condoms to prevent HIV infection costs about fourteen dollars. In a 2002 article in The Lancet, Andrew Creese from the World Health Organization and co-authors estimated that AIDS-prevention interventions such as condom distribution, blocking mother-to-child transmission, and voluntary counseling and testing could cost as little as one to twenty dollars per year of life saved, and twenty to four hundred dollars per HIV infection averted (even though this study may overstate the confidence that these things always work). Other studies come up with similar estimates.18

  Then there are other diseases for which Searchers have found cheap interventions (although we have seen that the Planners’ domination of aid often interferes with making these things work). The medicines that cure TB cost about ten dollars per case of the illness. A package of interventions designed to prevent maternal and infant deaths costs less than three dollars per person per year. Worldwide, three million children die a year because they are not fully vaccinated, even though vaccines cost only pennies per dose. One in four people worldwide suffers from intestinal worms, though treatments cost less than a dollar per year. A full course of treatment for a child suffering even from drug-resistant malaria costs only about one dollar. In fact, Vietnam, a relatively poor country, reduced deaths from malaria by 97 percent from 1991 to 1997 with a campaign that included bed nets and antimalarial drugs.19 A bed net program in Tanzania also reduced mortality significantly.20 (The availability of such cheap remedies makes it all the more tragic that malaria is still so widespread—we are back to the second tragedy of the world’s poor.)

  Overall, the World Bank estimates the cost per year for a variety of health interventions like these to range from five to forty dollars, compared with the fifteen-hundred-dollar cost of prolonging the life of an AIDS patient by a year with antiretroviral treatment. The $4.5 billion the WHO plans to spend on antiretroviral treatment for one more year of life for three million could grant between seven and sixty years of additional life for five times that many people—fifteen million. For the HIV-positive patients themselves, you could reach many more of them to prolong their lives by treating the opportunistic infections, especially TB, that usually kill AIDS victims.

  Other researchers come up with similar numbers. For example, Harvard economics professor Michael Kremer noted in an article in The Journal of Economic Perspectives in 2002: “for every person treated for a year with antiretroviral therapy, 25 to 110 Disability Adjusted Life Years could be saved through targeted AIDS prevention efforts or vaccination against easily preventable diseases.”

  A group of health experts wrote in the prestigious medical journal The Lancet in July 2003 about how 5.5 million child deaths could have been prevented in 2003, lamenting that “child survival has lost its focus.” They blamed in part the “levels of attention and effort directed at preventing the small proportion of child deaths due to AIDS with a new, complex, and expensive intervention.21

  The WHO expects the added years of life for AIDS patients from antiretroviral treatment to be only three to five years—not exactly a miracle cure.22 The United Nations Population Division in 2005 similarly estimated that the added years of life from antiretroviral treatment to be a median of3.5 years.23 After that, resistance to the first-line treatment (the one with the cheap drugs, which is all that is on the table in Africa, outside of South Africa) builds up and full-blown AIDS sets in. Other estimates are even more pessimistic. The average length of effectiveness of the first-line treatment in Brazil, which has a large-scale treatment program, has been only fourteen months.24

  The big question is whether poor Africans themselves would have chosen to spend scarce funds on prolonging some lives with AIDS treatment, as opposed to saving many lives with other health interventions. Would the desperately poor themselves, such as those on an income of one dollar a day, choose to spend fifteen hundred dollars on antiretroviral treatment? Should the West impose its preferences for saving AIDS victims instead of measles victims just because it makes the West feel better?

  Path of Least Resistance

  Getting a complex AIDS and development crisis under control just by taking a pill is irresistible to politicians, aid agencies, and activists. We see here again the bias toward observable actions by aid agencies. The activists’ cause plays well in the Western media because the tragedy of AIDS victims even has a villain—the international drug companies that were reluctant to lower the price on life-saving drugs—which makes mobilization for the cause even easier.

  AIDS treatment is another example of the SIBD syndrome—rich-country politicians want to convince rich-country voters that “something is being done” (SIBD) about the tragic problem of AIDS in Africa. It is easier to achieve SIBD catharsis if politicians and aid officials treat people who are already sick, than it is to persuade people with multiple sexual partners to use condoms to prevent many more people from getting the disease. Alas, the poor’s interests are sacrificed to political convenience. When the U.S. Congress passed Bush’s fifteen-billion-dollar AIDS program (known as the President’s Emergency Plan for AIDS Relief, or PEPFAR) in May 2003, it placed a restriction that no more than 20 percent of the funds be spent on prevention, while 55 percent was allocated for treatment.25

  In a fit of religious zealotry, Congress also required organizations receiving funds to publicly oppose prostitution. This eliminates effective organizations that take a pragmatic and compassionate approach to understanding the factors that drive women into prostitution. Programs that condemn prostitutes are unlikely to find a receptive audience when they try to persuade those prostitutes to avoid risky behavior.

  To make things even worse, the religious right in America is crippling the funding of prevention programs to advocate their own imperatives: abstain from sex or have sex only with your legally married spouse. Studies in the United States find no evidence that abstinence programs have any effect on sexual behavior of young people, except to discourage them from using condoms.26 The evangelists’ message has not convinced American youth, so the evangelists want to export it to African youth. Moreover, devout women who follow the sex-within-marriage mantra are still at risk if their husbands have sex with other partners without using condoms before or during their marriage. The religious right threatens NGOs that aggressively market condoms with a cutoff of official aid funds, on the grounds that those NGOs are promoting sexual promiscuity. Pushed by the religious right, Congress mandated that at least one third of the already paltry PEPFAR prevention budget go for abstinence-only programs.

  The Vatican is also pushing its followers to oppose condom distribution in Africa because of religious doctrine that forbids the use of birth control.27 These religious follies are one of the most extreme exampl
es of rich peoples’ preferences in the West trumping what is best for the poor in the Rest.

  While prevention is tied up in religious knots, everyone seems to agree on treatment. The gay community, a group usually not identified with the religious right, is also emphasizing treatment. Activist groups such as ACT UP helped along the push for treatment—in their Web site for the 2002 Barcelona AIDS conference, they mentioned “treatment” eighteen times, but didn’t mention “prevention” once.28 Why do we have a well-publicized Treatment Access Coalition when there is no Prevention Access Coalition? Why didn’t the WHO have a “3 by 5” campaign intended to prevent three million new cases of AIDS by the end of 2005? The activists have been only too successful in focusing attention on treatment instead of prevention. A LexisNexis search of articles on AIDS in Africa in The Economist over the previous two years found eighty-eight articles that mentioned “treatment” but only twenty-two that mentioned “prevention.”

  Instead of spending ten billion dollars on treatment over the next three years, money could be spent on preventing AIDS from spreading from the 28 million HIV-positive Africans to the 644 million HIV-negative Africans. Thailand has successfully implemented prevention campaigns targeting condom use among prostitutes, increasing condom usage from 15 percent to 90 percent and reducing new HIV infections dramatically. Senegal and Uganda have apparently also had success with vigorous prevention campaigns promoted by courageous political leaders (although the Ugandan government is now backing off from condom promotion under pressure from religious leaders).

  If money spent on treatment went instead to effective prevention, between three and seventy-five new HIV infections could be averted for every extra year of life given to an AIDS patient. Spending AIDS money on treatment rather than on prevention makes the AIDS crisis worse, not better. If we consider that averting an HIV infection gives many extra years of life to each individual, then the case for prevention instead of treatment gets even stronger. For the same money spent giving one more year of life to an AIDS patient, you could give 75 to 1,500 years of additional life (say fifteen extra years for each of five to one hundred people) to the rest of the population through AIDS prevention.

  We should ask the aid agencies why they want to put this much money now into the treatment of AIDS for twenty-nine million people when the same money spent to prevent the spread of HIV might have spared many of the twenty-nine million from infection. This past negligence is not an argument for or against any particular direction of action today—we must move forward from where we are now. But it does show how politicians and aid bureaucrats react passively to dramatic headlines and utopian ideals rather than according to where the small aid budget will benefit the most people. Is this what poor people themselves would choose to spend the money on?

  Trade-offs

  It is the job of economists to point out trade-offs; it is the job of politicians and Planners to deny that trade-offs exist. AIDS campaigners protest that AIDS treatment money is “new money” that would have been otherwise unavailable, but that just begs the question of where new money is best spent. Why are there not campaigns to spread even further the successful campaigns against children’s diarrhea, where a given amount of money—raised from the same sources—would reach many more people than money for AIDS treatment?

  The utopian reaction is that the West will spend “whatever it takes” to cover all the health programs described above. This was the approach taken by the WHO Commission on Macroeconomics and Health in 2001. This commission recommended that rich countries spend an additional twenty-seven billion dollars on health in poor countries by 2007, which at the time was more than half of the world’s foreign aid budget to poor countries. They ramp this number up to forty-seven billion dollars by 2015, of which twenty-two billion would be for AIDS. The commission’s report was influential in gaining adherents for AIDS treatment in poor countries.

  In an obscure footnote to the report, the commission notes that people often asked it what its priorities would be if only a lower sum were forthcoming, but it says it was “ethically and politically” unable to choose. The most charitable view is that this statement is the commission’s strategy to get the money it wants. Otherwise, this refusal to make choices is inexcusable. Public policy is the science of doing the best you can with limited resources—it is dereliction of duty for professional economists to shrink from confronting trade-offs. Even when you get new resources, you still have to decide where they would be best used.

  If you want priorities and trade-offs, you can get them in the WHO itself. The WHO’s 2002 World Health Report contains the following common sense: “Not everything can be done in all settings, so some way of setting priorities needs to be found. The next chapter identifies costs and the impact on population health of a variety of interventions, as the basis on which to develop strategies to reduce risk.29

  The next chapter in the WHO report actually states that money spent on educating prostitutes saves between one thousand and one hundred times more lives than the same amount of money spent on antiretroviral treatment.30

  Getting back to the WHO Commission on Macroeconomics and Health, the commission’s sum, according to its own assumptions, did not eliminate all avoidable deaths in the poor countries. These sums, not to mention total foreign aid, are paltry relative to all the things that the world’s three billion desperately poor people need. The commission did place some limit on what it thought rich countries were willing to spend to save lives in poor countries. Everybody places limits on what they spend on health. Even in rich countries, people could maximize their chances of catching killer diseases early enough for treatment by, say, having a daily MRI. Nobody, except possibly Woody Allen, actually does this, because it’s too costly relative to the expected gain in life and relative to other things that rich people would like to spend money on. Virtually nobody was advocating AIDS treatment in Africa when the drug cocktail cost more than ten thousand dollars per year. Everybody, except political campaigners, knows that money, whether “new” or “old,” is limited.

  A political campaigner giving a graphic description of AIDS patients dying without life-saving drugs is hard to resist, making the trade-offs described earlier seem coldhearted. But money should not be spent according to what the West considers the most dramatic kind of suffering. Others with other diseases have their own chronicles of suffering. The journalist Daniel Bergner describes the relentless wailing of mothers in Sierra Leone who have lost a child to measles, the wailing that never stopped in a village during a measles epidemic. The high fever of measles stirs up intestinal worms, which spill out from the children’s noses. Sores erupt inside their mouths. The parents in desperation pour kerosene down the children’s throats. The graves of the dead children lie behind their parents’ huts, mounds of dirt covered by palm branches.31

  Take also the small baby dying in his mother’s arms, tortured by diarrhea, which can be prevented so easily and cheaply with oral rehydration therapy. Many deaths can be prevented more cheaply than treating AIDS, thus reaching many more suffering people on a limited aid budget. Nobody asks the poor in Africa whether they would like to see most “new” money spent on AIDS treatment as opposed to the many other dangers they face. The questions facing Western AIDS campaigners should not be “Do they deserve to die?” but “Do we deserve to decide who dies?”

  Constance, the HIV-positive mother from Soweto whom I mention at the beginning of this chapter, had an interesting perspective on priorities. When I asked her to name Soweto’s biggest problem, she did not say AIDS or lack of antiretroviral treatment. She said, “No jobs.” Finding a way to earn money to feed herself and her children was a more pressing concern for her than her eventual death from AIDS.

  The more sophisticated way to deny that trade-offs exist is to insist that each part of the budget is necessary for everything else to work. When asked to choose between guns and butter, the canny politician insists that guns are necessary to protect the butter
. In the AIDS field, strategic responses gave us the mantra “prevention is impossible without treatment.” The proposition rests on the plausible reasoning that people will not come forward to be tested (most HIV-positive Africans do not know they are HIV-positive) unless there is hope of treatment. Some bits of evidence support this intuition, but the notion has not really been subjected to enough empirical scrutiny. Moreover, it is also plausible, and there is also a little evidence, to support the idea that treatment makes prevention more difficult. There is evidence that people in rich countries engaged in riskier sexual behavior after HAART became available.32 Prevention campaigns did work in Senegal, Thailand, and Uganda without being based on treatment. Finally, there remains the risk that treatment with imperfect adherence will result in emergence of resistant strains of HIV, so that treatment itself will sow the seeds of its own downfall.33

  Dysfunctional Health Systems

  Admittedly, these trade-offs are oversimplified. Cost-effectiveness analysis—which compares different health interventions according to their estimated benefits (years of lives saved) and costs (drugs, medical personnel, clinics, hospitals)—gives us these numbers. This is the mainstream approach in the international public health field. Many of the advocates for treatment, such as Grö Harlem Brundtland and WHO staff, buy into this approach. They just fail to follow the logic through to the conclusion that you could save many more lives spending on other health interventions—including AIDS prevention—with what they propose to spend on AIDS treatment.