Lant Pritchett of Harvard’s Kennedy School and Jeffrey Hammer and Deon Filmer of the World Bank criticize these cost-effectiveness calculations for the oversimplifications they are. Just because it costs a dollar to treat a person’s illness, it doesn’t follow that giving a dollar to the national health system will result in treating that person. We have already seen what a difficult time international aid planners have in getting even simple interventions to work.
Despite the health successes noted earlier, Filmer, Hammer, and Pritchett talk about “weak links in the chain” that leads from the donor’s dollar to the person’s treatment. The second tragedy of the world’s poor means that many effective interventions are not reaching the poor because of some of the follies of Planners mentioned in previous chapters.
Because of the insistence on working through governments, funds get lost in patronage-swollen national health bureaucracies (not to mention international health bureaucracies). In countries where corruption is as endemic as AIDS, health officials often sell aid-financed drugs on the black market. Studies in Cameroon, Guinea, Tanzania, and Uganda estimated that 30 to 70 percent of government drugs disappeared before reaching the patients. In one low-income country, a crusading journalist accused the ministry of health of misappropriating fifty million dollars in aid funds. The ministry issued a rebuttal: the journalist had irresponsibly implied that the fifty million dollars had gone AWOL in a single year, whereas they had actually misappropriated the money over a three-year period.
I have heard from multiple sources of AIDS money disappearing before it reached any real or potential victims. In Cameroon, the World Bank lent a large amount for AIDS, which the health ministry handed out to local AIDS committees. Critics allege there was virtually no monitoring and no controls and are not quite sure what the local committees did, except for vaguely defined “AIDS sensitization.” In one alleged case, a local committee chair threw a large party for his daughter’s wedding under the category of “AIDS sensitization.”
Many doctors, nurses, and other health workers are poorly trained and poorly paid. The AIDS treatment campaigners are oblivious to these harsh realities of medical care in poor countries. The worst part about the heart-felt plea for money for AIDS treatment is that it will save many fewer lives than campaigners promise.
Of course, similar arguments would also weaken the case for the allegedly more cost effective health interventions on illnesses such as diarrhea, malaria, and measles. They do not work everywhere as well as they should, as the rest of this book makes clear. But this complication does not strengthen the argument for funding AIDS treatment in Africa. The cheap interventions have some successes, as noted earlier. They are cheap because they are simpler for Searchers to find ways to administer—a measles vaccination has to happen only at one given point just for each child. A bed net impregnated with insecticide has to be handed out just once to each potential malaria victim, along with the information on how to use it, then impregnated again periodically.
The treatment of AIDS with drugs is vastly more complicated and depends on many more “links in the chain”: refrigeration, lab tests, expert monitoring and adjusting therapy if resistance and toxic side effects emerge, and educating the patient on how to take the drug. In Europe and North America, 20 to 40 percent of AIDS patients do not take their drugs as prescribed. Resistance will emerge if there are lapses from the correct regimen. Even with good intentions, government bureaucrats currently do a poor job making sure that drug supply matches demand in each locale. Unfortunately for the patients, it is critical that AIDS treatment not be interrupted by drug shortages (critical both for effectiveness and for preventing resistant strains from developing). A 2004 article in the Journal of the American Medical Association, while generally positive about treatment in developing countries, sounded some concerns:
Finally, how will the tens of thousands of health care professionals required for global implementation of HIV care strategies be trained, motivated, supervised, resourced, and adequately reimbursed to ensure the level of care required for this complex disease? To scale up antiretroviral therapy for HIV without ensuring infrastructure, including trained practitioners, a safe and reliable drug delivery system, and simple but effective models for continuity of care, would be a disaster, leading to ineffective treatment and rapid development of resistance..34
Even doing the huge amount of testing required to find out who is HIV-positive and eligible for treatment would likely overwhelm health budgets and infrastructure in poor countries.
The tardy response to the AIDS crisis has meant that it has built up to an unbearable tragedy—to the point that it’s now too late to save many millions of lives. Spending money on a mostly futile attempt to save all the lives of this generation of AIDS victims will take money away from saving the lives of the next generation, perpetuating the tragedy. The political lobby for treatment doesn’t mention that no amount of treatment will stop the crisis. The only way to stop the threat to Africans and others is prevention, no matter how unappealing the politics or how uncomfortable the discussion about sex. The task is to save the next generation before it is again too late.
Let’s commend the campaigners wanting to spend money on AIDS treatment in Africa for their dedication and compassion. But could they redirect some of that compassion to where it will do the most good?
Feedback and Idealism Again
Why did the health system fail on AIDS when foreign aid successes are more common in public health than in other areas? The AIDS crisis was less susceptible to feedback, and the interests of the poor were not coincident with rich-country politics. The necessary actions were in the area of prevention, which doesn’t involve just taking a pill or getting a shot, as in many of the other successes. The donors showed shamefully little interest in researching the sexual behavior that causes AIDS to spread or in which prevention strategies work to change that behavior. Donors should have asked, “How many people have we prevented from becoming HIV-positive?”
A patient who is already HIV-positive is a highly visible target for help—a lot more visible than someone who is going to get infected in the future but doesn’t yet know it. The rich-country politicians and aid agencies get more PR credit for saving the lives of sick patients, even if the interests of the poor would call for saving them from getting sick in the first place. This again confirms the prediction that aid agencies skew their efforts toward visible outcomes, even when those outcomes have a lower payoff than less visible interventions.
The politicians and aid agencies didn’t have the courage to confront the uncomfortable question of how to change human sexual behavior. The AIDS failure shows that the bureaucratic healers too often settle for simply handing out pills.
Heroes
The AIDS disaster in Africa features many ineffective bureaucrats and few energetic rescuers. But there are a few heroes. A group called HIVSA works in Soweto, South Africa, helping people like Constance. Its energetic director, Steven Whiting, was formerly an affluent interior designer. He stumbled on the AIDS issue by chance when he got the contract to renovate the headquarters of the Perinatal HIV Research Unit at the largest hospital in Soweto. He was so moved by what he saw there that he decided to quit his job and devote his efforts full time to fighting AIDS.
HIVSA does the little things that make a difference. It provides the drug nevirapine to block transmission of the HIV virus from mothers to newborns. Doctors give just one dose during labor, an intervention that is highly cost effective compared with other AIDS treatments. To follow up, HIVSA provides infant formula to HIV-positive new mothers, since breast-feeding can also transmit the HIV virus to newborns. Less tangibly, HIVSA provides support groups meeting in health clinics throughout Soweto to help HIV-positive mothers confront the stigma of HIV and their many other problems. (One hint of such problems: the signs all over the clinics announcing that no guns are allowed inside the clinics.) When the mothers visit the clinics, they get a free meal and nut
ritional supplements. Mothers and HIVSA staff work in community gardens attached to each clinic to provide food. HIVSA staff are almost all from the Soweto community and are HIV-positive.
Constance has problems that are overwhelming, but her most recent baby was born HIV-negative, thanks to nevirapine. HIVSA’s free meals, nutritional supplements, and emotional support make her life a little more bearable.
If only all the West’s efforts at fighting AIDS were so constructive at giving the poor victims what they want and need. The West largely ignored AIDS when it was building up to a huge humanitarian crisis, only to focus now on an expensive attempt at treatment that neglects the prevention so critical to stop the disaster from getting even worse.
SNAPSHOT: PROSTITUTES FOR PREVENTION
PROSTITUTES IN SONAGACHI, the red-light district of Calcutta, India, form a world unto themselves. Social norms about female sexual behavior in India are such that prostitution carries an even larger stigma in India than elsewhere. Cut off from the wider world, prostitutes have their own subculture, with an elite of madams and pimps. As in any subculture, its members strive for status. Prostitutes who aspire to greater status attain it most commonly by attracting long-term clients.
Many well-intentioned bureaucrats have tried to help the prostitutes by “rescuing” them and taking them to shelters to be trained in another profession, such as tailoring. However, sex work pays a lot better than tailoring, and former prostitutes face harassment and discrimination in the outside world. Hence, most “rescued” women returned to prostitution. But the advent of the AIDS epidemic in India and the well-known role of prostitutes in spreading AIDS caused increased concern about these failures.
Dr. Smarajit Jana, head of the All India Institute of Hygiene and Public Health, had another idea in 1992. He and his team would learn the subculture of the prostitutes and work with it to fight AIDS. They formed a mutually respectful relationship with the madams, pimps, prostitutes, and clients. They noted the class system within Sonagachi. By trial and error, and with feedback from the prostitutes, Dr. Jana and his team hit upon a strategy for fighting AIDS. The strategy was awfully simple in retrospect: they trained a group of twelve prostitutes to educate their fellow workers about the dangers of AIDS and the need to use condoms. The peer educators wore green medical coats when they were engaged in their public health work, and they attained greater status in Sonagachi. Condom use in Sonagachi increased dramatically. By 1999, HIV incidence in Sonagachi was only 6 percent, compared with 50 percent in other red-light districts in India.
The project had other, unexpected consequences. The increased confidence of the peer educators and the media attention on the success of prevention efforts led the community to aspire to greater things. The prostitutes formed a union to campaign for legalization of prostitution and a reduction in police harassment, and to organize festivals and health fairs. Dr. Jana’s approach based on feedback from the intended beneficiaries succeeded when so many other AIDS prevention programs had failed.
PART III
THE WHITE MAN’S ARMY
CHAPTER EIGHT
FROM COLONIALISM TO POSTMODERN IMPERIALISM
The curious task of economics is to demonstrate to men
How little they really know
About what they imagine they can design.
F.A. HAYEK, THE FATAL CONCEIT:
THE ERRRORS OF SOCIALISM, 198.1
IMPERIALISM IS COMING BACK into fashion in the West. Western journalists report locals harboring nostalgia for colonialism in Sierra Leone or even for white-minority regimes in Zimbabwe. Other prominent Western journalists write about “The Case for American Empire.2
Prominent political scientists James Fearon and David Laitin of Stanford wrote in the spring of 2004:
The United States is now drawn toward a form of international governance that may be described as neotrusteeship, or more provocatively, postmodern imperialism. The terms refer to the complicated mixes of international and domestic governance structures that are evolving in Bosnia, Kosovo, East Timor, Sierra Leone, Afghanistan and, possibly in the long run, Iraq. Similar to classical imperialism, these efforts involve a remarkable degree of control over domestic political authority and basic economic functions by foreign countries.
Fearon and Laitin conclude that “the current, ad hoc and underrationalized arrangements ought to be reformed in the direction of neotrusteeship.3
Altogether, five different articles in Foreign Affairs, the bible of the policymaking elite, in the past few years have considered some variant of “post-modern imperialism” for ailing states.4 In a similar vein, political scientist Stephen Krasner (also of Stanford) writes in the fall of 2004:
Left to their own devices, collapsed and badly governed states will not fix themselves because they have limited administrative capacity, not least with regard to maintaining internal security. Occupying powers cannot escape choices about what new governance structures will be created and sustained. To reduce international threats and improve the prospects for individuals in such polities, alternative institutional arrangements supported by external actors, such as de facto trusteeships and shared sovereignty, should be added to the list of policy options.
He concludes: “De facto trusteeships, and especially shared sovereignty, would offer political leaders a better chance of bringing peace and prosperity to the populations of badly governed states.” Secretary of State Condoleezza Rice appointed Stephen Krasner to be head of policy planning at the State Department on February 4, 2005.
As Naomi Klein wrote in The Nation on May 2, 2005, the U.S. State Department has an interesting new office:
On August 5, 2004, the White House created the Office of the Coordinator for Reconstruction and Stabilization, headed by former U.S. Ambassador to Ukraine Carlos Pascual. Its mandate is to draw up elaborate “post-conflict” plans for up to twenty-five countries that are not, as of yet, in conflict…. Pascual told an audience…in October, will have “pre-completed” contracts to rebuild countries that are not yet broken…. The plans Pascual’s teams have beendrawing up…are about changing “the very social fabric of a nation.”…The office’s mandate is not to rebuild any old states…but to create “democratic and market-oriented” ones…. Some-times rebuilding, he explained, means “tearing apart the old.”
Stephen Krasner and Carlos Pascual wrote an article for Foreign Affairs in July/August 2005 explaining further how all this would work. Like their foreign aid counterparts, Krasner and Pascual are Planners:
During U.S. or other military or peacekeeping operations, the new office will coordinate stabilization and reconstruction activities between civilian agencies and the military. As part of the military’s planning effort, interagency civilian teams will deploy to regional combatant commands to develop strategies for stabilization and reconstruction. This type of involvement will help make certain that assumptions about civilian reconstruction capabilities remain realistic. After the planning stage, advance civilian teams will deploy with the military to help direct stabilization and reconstruction.
Further, they said, there will be coordination with the other kind of foreign aid, the one that involves USAID, the World Bank, and the IMF. Krasner and Pascual offer the hope that “the United States will have enabled more people to enjoy the benefits of peace, democracy, and market economies.5
It used to be that everybody agreed that colonialism was bad. Frustration with disastrous postcolonial outcomes in Africa has led many to imagine a colonial past of peace and prosperity. More sophisticated scholars have also challenged the conventional wisdom of evil colonialism. Harvard historian Niall Ferguson, whose work on every topic but this one I greatly admire, says that there is “such a thing as liberal imperialism and that on balance it was a good thing…in many cases of economic ‘backwardness,’ a liberal empire can do better than a nation-state.6
Such ambitious claims have provoked this economist to venture outside of normal economics territory, to considering e
conomic development as pursued through military occupation, invasions, and nation-building. Certainly this part of the book is looking at a set of actors different from those in the rest of the book—most of the advocates of foreign aid are horrified at the idea of imperialism and colonialism, new or old, and so this chapter is less relevant for them. Yet the neo-imperialists represent an influential approach to ending world poverty that needs to be addressed.
Following the familiar escalation syndrome, failed intrusions of the West provide the motivation for the West to become even more intrusive. Aid failed in the sixties and seventies because government was bad, and the West used that to justify structural adjustment to induce governments to change in the eighties and nineties. Structural adjustment failed to change governments in the eighties and nineties, so now some in the West entertain replacing national government altogether with “trusteeship” or “shared sovereignty” for the most extreme failures.
This chapter argues that the old conventional wisdom was correct—the previous imperial era did not facilitate economic development. Instead, it created some of the conditions that bred occasions for today’s unsuccessful interventions: failed states and bad government. The West sowed further mayhem with chaotic decolonization, especially the arbitrary way the West drew borders. Although many will deny the relevance of colonial experience to today’s allegedly more humanitarian exercises, I argue that there are many lessons to be gained from the previous wave of Western intervention in the Rest—as many problems were created by colonizers’ incompetence as by their exploitation. It is at least ironic that some offer a new White Man’s Burden to clean up the mess left behind by the old White Man’s Burden.
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