TCS Daily

It's Over... For Now

By Roger Bate - September 10, 2003 12:00 AM

One of the great successes of Gro Harlem Brundtland's reign at the World Health Organisation was her ability to drive health concerns up the international policy agenda. While every policy issue has been eclipsed by security concerns since September 11th 2001, health issues now take a proud second place at many international meetings.


WHO's public relations are impressive. It apparently controlled the SARS outbreak gaining political and media plaudits. But less well-known is WHO's support for kick-starting poor countries' health infrastructure with aid. Aid is as dangerous for health projects as it was for road building and dam construction.  It breeds long-term dependency and quickly becomes counter-productive. The WHO mantra that 'healthy countries are wealthy countries' is true, but the causation is the other way around. Wealth generation comes before health spending; it is essential that countries become self-sufficient by becoming wealthy through capitalism. Ironically the aid that is sent to improve health may inhibit wealth generation setting in motion a vicious, rather than a virtuous, cycle.


As diplomats arrive in Cancun for the World Trade Organisation Ministerial meeting, they will be relieved that a deal has been struck about access to drugs. Regardless of the sense of this deal, there is no doubt that the focus on the failure of developing countries to combat the AIDS pandemic will now, at least somewhat, switch from patents to lack of African government interest in the disease, and the alleged paucity of western aid.


Strange Alliances


The patents issues saw strange alliances form and flourish. The generics companies of India and Brazil were closely aligned with western health activists and left-leaning academics. Other largely apolitical and empirically driven academics, free market advocates and western drug companies opposed them, correctly identifying the fact that patents were not a problem (and were in fact essential to ongoing research) in most African settings. But we may start to see these alliances dissolve somewhat over the next few months, at least if the WTO patent deal holds.


The academics, led by Jeffrey Sachs, who have done much to provide the good sense in the debate about patents, have complained bitterly about the stinginess of western countries when it comes to aid delivery for AIDS. They acknowledge that aid has been wasted in the past, and has even been counterproductive, but claim that the AIDS pandemic, 'the worst disease since the black death killed a third of Europe 600 years ago', is uniquely different and deserving of aid.  Stung by the criticism, President Bush has stepped up with an announced, although still to be appropriated, $10 billion of new money over the next five years.  The sentiment behind this announcement is no doubt welcome. Some countries in Africa are suffering so badly under the weight of AIDS that they need to combat the disease to prevent a complete economic collapse. But many countries, through famine and war, have known similar disasters and aid has not helped them. And in the long run aid will not help AIDS-ravaged countries.


Successful Aid?


The Rockefeller Foundation, the WHO and other development agencies managed to control, and in some places eradicate, malaria from many African and Asian countries. They did it by spraying DDT in large quantities and saved millions of lives in the process. But the gains proved impossible to sustain in countries that did not have the requisite legal and social institutions of capitalism. Without capitalism there is no wealth and without wealth good health is a mirage. Only capitalism sustainably uses new technological advances.


For example, Malaysia shares a border with Singapore, today the latter has no malaria, while the former has thousands of cases a year. Both had malaria largely eradicated in the 1960s but Malaysia never developed as rapidly as Singapore and hence did not have the general health infrastructure in place. Most importantly its people did not get wealthy enough to buy drugs, live in houses with screens, pay for mosquito larvicides and other mosquito prevention activities.


As donor fatigue increased across Africa and Asia, due to the failure to eradicate malaria, less aid meant that spray programs became less well monitored and effective, and terminal decline of programs became inevitable. Singapore and other wealthy countries like Italy, Greece and the US, maintained a malaria-free existence long after major eradication efforts were stopped, whereas the disease once again burdens poorer countries such as Guyana, Sri Lanka and Belize, which were temporarily free of malaria.


Of course, there is no doubt that aid agencies have learnt from some of the mistakes made in programs like this and aid is better targeted and monitored today. And if aid had no long run harm its short-term benefits would certainly be worth the money. But entire networks develop to milk the aid system, which then often prevents entrepreneurial, sustainable development from occurring. Most African countries are incapable of doing what their citizens most require because they are wedded to aid and the strings that are attached to it. For malaria, the aid agencies just promote bed nets, even though what is most required is pesticide spraying; for AIDS they demand cheap drugs but don't provide training for nurses to administer them.


Most aid agencies (and certainly the aid givers on the ground) are politically left-leaning. They may pay lip service to the private sector but far prefer dealing with socialist NGOs, and the like-minded Government bureaucracies, with which they are most familiar. The tendency is to privately scoff at private sector attempts to deliver better health, and they often make it impossible for private approaches to work, usually by rousing opposition to the dangers of 'profit'. The result is that when the private sector gets involved, such as in the AIDS programs in Botswana, the results are better, but they are still not sustainable, because the companies do not want to be accused of making money. For how long can drug company Merck continue to give $10m a year to Botswana, as well as provide free drugs? Merck's largess is impressive, but the company is not large enough to provide the same benefits to all African countries, nor should it. One wonders what its shareholders would think of such spending if maintained perpetually.


Africa is a mess of a continent, but throwing aid at it will not help. As James Shikwati of Kenya's Inter-Regional Economic Network explains: 'we need to be free to develop, unencumbered by well-meant, but ultimately harmful, aid'.


Dr. Roger Bate is US Director of health advocacy group Africa Fighting Malaria and a visiting fellow at the American Enterprise Institute.

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