TCS Daily

Learning From the Past

By James Pinkerton - November 24, 2003 12:00 AM

Can we find a way to fight AIDS without defeating ourselves in the process? Well-meaning people around the world have united around the wonderful idea of spending billions to help millions. And since what's been done so far hasn't worked to brake the rising tide of disease and death, new and better approaches are needed. The search for new approaches was the major theme of a November 12 conference on AIDS convened on Capitol Hill. The consensus was that to achieve those goals, new organizations, committed to new techniques, must be brought into existence, ASAP. The catch, of course, is that we've seen this rushed and radical de-bureaucratization before; it failed disastrously in the 60s -- that was the point of Part One.


Today, looking ahead, we can only hope that current policy makers know better, even if their rhetoric is eerily reminiscent of those bad old days.


To be sure, de-bureaucratization per se is a good thing. Indeed, paradoxical as it may seem, the corporate renaissance of the past quarter-century has been led precisely by those revolutionaries who took a radical approach to getting things done. The vastly successful restructuring of corporate America -- flattening hierarchical pyramids, de-layering bureaucracy, empowering decisionmakers at the lowest possible level -- was led by visionaries who had every bit as much ambition and energy as the Great Societeers who made such a hash of things in the public sector.


So how to balance the need to bust the bureaucracy with the even greater need to boost the bottom line? It's hard to strike this creative and constructive balance, which is why those who succeed stand out as stars. One such star is Randall Tobias, the former CEO of Eli Lilly, now America's Global AIDS Coordinator, who recalled his own successful tenure at Lilly in his speech, and in a brief interview afterward. He hearkened back to his Indianapolis days, when he set up "cross-functional teams" -- forcing different groups, such as accounting and manufacturing -- to work together in unfamiliar ways.


Tobias now has pledged to translate this same innovating spirit from the private sector into the public sector. "This represents a new way of doing business," he said of his global AIDS work, adding, "We intend to tear down the walls between agencies, and apply focused attention based on the individual needs of the countries." Does that sound a bit like the community action model of 40 years ago -- "activities based on what poor people actually wanted from government, rather than what bureaucrats in Washington thought they needed" -- described in Part One?


Yes, but. The difference, of course, is that in the private sector, corporate leaders are generally held to strict standards of accountability -- by the board of directors, by the shareholders and, most importantly of all, by the marketplace. A CEO who re-engineers his corporation for the better is rewarded; a CEO who simply swings a wrecking ball is punished and removed. So while visionary business guru Tom Peters can write a book with the provocative title of Thriving on Chaos, the company following his advice had better thrive -- or else.


Alas, the public sector has few of those obvious checks and balances against poor performance. In politics, failure can be hidden behind the cloaking rhetoric of moral crusading, grievance-nursing and, of course, that all-purpose perennial, "social justice." Throw enough of those buzzwords and buzz-concepts around, and almost any social-policy calamity can be concealed, at least for a while.


So what will it be this time? Failure, or success?


One difference today is that Tobias & Co. seem focused on outcomes, not just inputs. Yes, they emphasize the importance of inputting all that money, drawn from all those sources, but they also emphasize outcomes -- preventing, treating, providing care.


But of course, tracking outcomes isn't always easy. And always wonders whether the data that an organization provides are reliable. Remember the Vietnam "body counts"? They "proved" that we were winning in Vietnam -- until, of course, we lost. And now to AIDS -- how are we going to measure, for example, the fact that we prevented seven million infections? How does one precisely quantify non-events like that? The point here isn't to tear down a whole enterprise, but rather to emphasize the importance of rigorous cost/benefit analysis, because the inputs -- money, labor, and time -- are real enough and easy to measure; it is the outputs that can be tricked up and made slippery by globalcratic spin doctors.


So reliability of results will be a big challenge to the AIDS fighters. Tobias will need to verify his results now as closely as he verified Lilly's bottom line. And here are more challenges he will face:


First, it's one thing to talk about "cross-functional teams," as he did on Capitol Hill; it's another thing to make them work in Botswana, or some other far-away place. Why? Most obviously, there are the usual concerns about waste, fraud, and abuse, which are inherent in any start-up.


But matters of international politesse must be considered, too. Kereng Masupu, head of Botswana's National AIDS Coordinating Agency, was the next speaker at the Capitol Hill conference, immediately after Tobias. Having heard the American say that the goal was to knock down walls and barriers, the Botswanan said, in effect, that walls and barriers were a good idea. "The response must be in line with sovereignty," Masupu maintained, and all "partnerships must be reviewed" by the government. Is he wrong? It is, after all, his country; he and his countrymen have plenty of bad memories of Western colonialism to grapple with. Indeed, one lesson of development in the past few decades is the importance of cultural sensitivity; otherwise the best plan on a chalk board, or on a PowerPoint, will fail in practice.


And Masupu's leader, Botswanan President Mogae, raised another issue in his speech, the issue of "brain drain." Masupu's point was that at the very moment when medical professionals are desperately needed in Botswana, the very countries that are pledging aid are hiring away needed medical talent. As Mogae noted, Britain alone has recruited 120 of his country's best nurses to work in the United Kingdom.


The third possible problem is closely related to the issue of "human capital" in Botswana and the rest of the Third World. And that is the danger that simple provision of medicines can be unproductive, even counter-productive. If a complicated pill-taking regimen is not followed precisely, not only is the patient not cured, but the AIDS virus gets a chance to mutate, and thus adapt to the new medicine. It's important to emphasize that problems of dosage are universal, not confined to Africa, or event the Third World.


As an aside, reports that of the 157 Marines of the 26th Expeditionary Unit who went ashore in Liberia last month and spent at least one night in country, no fewer than 69 contracted malaria. As the website observes, "This large outbreak of malaria among Marines was apparently caused by a nearly wholesale failure of the troops to follow protective measures, particular by not taking a once-a-week malaria-preventing drug." Which is to say, if uniformed personnel, living under military discipline, can't be relied up to take one pill a week, then no wonder it's hard to succeed in enforcing such medicinal regimens in an impoverished civilian environment. In other words, fighting AIDS isn't easy.


So it is that all the billions spent on treatments over the past two decades could yet be undone by poor health care delivery. In fact, the science of fighting all infectious diseases, including AIDS is still uncertain; a headline from the Associated Press declared on November 12: "Experimental AIDS vaccine fails major test in Thailand." The news was that the Australian company VaxGen spent a fortune on clinical trials in both Bangkok and the US, and now it has nothing but red ink to show for its years of R&D.


One might hope, of course, that VaxGen and all pharmaceutical companies will keep at it, keep fighting the good fight. But now we come to the fourth potential problem. Everyone wants abundant anti-AIDS drugs, constantly updated and improved to deal with evolving strains of the disease. And, of course, everyone wants them cheap, or even free. Today, Big Pharma has pretty much abandoned the idea of making a profit -- that is, gaining a return on billion-dollar investments -- on drugs for AIDS headed for the Third World. A similarly red-inky trend is also evident for malaria and tuberculosis drugs. That's charitable and laudable, but how long will it last? How long would you stay in a business that didn't turn a profit?


A fifth possible problem -- make that a definite problem -- is a general climate of radicalism that degenerates into nihilism. Mogae, Tobias, Gayle, and all the other countries and companies might be doing their best, but of course, whatever they do will never be good enough in the eyes of some extremists. Flying around the Internet these days are missives from a CAA -- oops, NGO -- called Health GAP (Global Access Project) that is attempting to mobilize demonstrators for a rally in Washington DC on November 24: "Protest because President Bush lied when he told our nation during his State of the Union Address, that 'we have confronted, and will continue to confront, HIV/AIDS in our country,' and he lied when he said the US government will 'respond as generously as we can' in fighting AIDS in sub-Saharan Africa and around the world." And December 1st, proclaims a British NGO, is "World AIDS Day"; one might expect more protests on that date. Free speech isn't inherently destructive, of course, but distortions of the truth inhibit problem-solving. And if the course of anti-poverty efforts during the '60s offers any present-day parallel, there's a danger that vanguard forces will simply go crazy, causing everything they touch to get worse. As noted above, the big loser in such radicalism would be an orderly and, hopefully, profitable approach to finding new cures for AIDS and other diseases.


These five concerns, one hopes, can all be dealt with. First, surely it's possible to develop a plan for fighting AIDS around the world that takes into account the realities of the Third World -- in which, as even The New York Times conceded in its report on the conference, the biggest problem is not lack of funding. Second, the "brain drain" problem can be addressed by concentrating more effort on incentivizing health care professionals to stay in their home countries. Third, competent professionals can manage the disbursement of drugs, so that faulty regimens do not undermine the efficacy of the drugs themselves. Fourth, the basic economic realities of pharmaceutical R&D will be borne in mind; leaders will not succumb to demagoguery and kill the goose that lays the golden eggs of cure. Fifth, and closely following, radicals pushing their avant-garde agenda of socialism or redistributionism will not be allowed to subvert the global anti-AIDS effort. These ideal scenarios are what one hopes for.


It's thrilling to be part of something new. And in such a heady time, when everything seems possible, when everyone is embarked on an heroic voyage, it may seem almost churlish to point out that there are obstacles ahead. But they must identified, mapped, and avoided; otherwise, the venture will crack up. The failure of the Great Society of the '60s can serve as a valuable lesson for the Great AIDS Crusaders of the '00s, but only if they look back and learn.



TCS Daily Archives