Extreme poverty in Africa: glass half full?

Sometime in the next few days I was planning to post a link to the new UNICEF figures on global child mortality (once I had taken a look at the report), but Jeffrey Sachs in the NYT (via) beat me to it (at least w/r/t the figures for Africa).

Sachs has a glass-half-full view of poverty and its effects in Africa, observing, among other things, that malaria is down by 30 percent (over what period exactly he doesn't say) and that economic growth is up to 5.7 percent in the period 2000-2010. He doesn't discuss how that growth has been distributed, however. And the child mortality figures, although better than they were, are still terrible: almost 10 percent under-5 mortality per 1000 births in 2012 (or in plain language, for every 1000 children born, 98 died before their fifth birthday). [ETA: Oh yes, the (supposedly) key figure: the percent living below the W.Bank's $1.25-a-day extreme poverty line was down to 49 percent in 2010 for sub-Saharan Africa, 21 percent for developing countries taken altogether.]  

Sachs is probably right that private-public 'partnerships' are required to make progress on further reducing extreme poverty. But structural reforms are also needed, such as, to mention just one, ending offshore tax havens that cost developing countries more money every year than they receive in official development assistance. This last point I take from a book that I've checked out of the library but as yet have only glanced at: Gillian Brock, Global Justice: A Cosmopolitan Account (Oxford U.P., 2009). She discusses taxation and its connection to global poverty in chap.5. (I'm assuming this particular problem is as bad now as it was several years ago when Brock wrote. In the unlikely event that's wrong, someone can correct me.)

QOTD: Gates on eradicating polio

Excerpted from an interview with E. Klein:

Ezra Klein: How do you ensure you hit every tiny village in a mountainous, rural, poor country?

Bill Gates: We began using satellite maps and we’re finding particularly in Nigeria we were missing a lot of settlements, a lot of nomadic people. The thing we were missing the most was a village would be on a border, and one government would say, “Oh, that’s on their side,” and the other guy would say, “No, that’s on their side.” So your chance of getting polio was super elevated if you happened to live on the border between these local government administrative boundaries.

Then in terms of the teams doing their job, we now put a phone with a GPS sensor in it, every three minutes it says where this team is. It’s in the box with the vaccine so when they come in at the end of the day we plug that in and see if they really went where they were supposed to go.

Our biggest problems now are violence, which causes campaigns to be canceled, or people just not ... willing to go into various neighborhoods, and refusals having to do with bad rumors about the vaccine campaign. And these are both serious issues in both Pakistan and Nigeria.

New estimates of malaria death rates in India

A study published in the Lancet suggests that roughly 200,000 deaths per year in India are due to malaria, a figure some 13 times higher than the World Health Organization estimates. As this BBC story notes, about 1.3 million deaths from infectious diseases, with acute fever as the main symptom, occur in rural parts of India each year, but the causes of these deaths are hard to determine, since most of them are not medically certified. The Lancet study used an interview technique called verbal autopsy. The WHO says the study's estimates are too high, but this story certainly raises questions about the numbers of those dying from this preventable disease. The study was jointly funded by NIH, the Canadian Institute of Health Research, and Li Ka Shing Knowledge Institute.

The debasement of public debate

Democracy is the worst form of government except for all the others, Churchill once supposedly remarked. One of democracy's virtues, at least as it is presented in civics books and the writings of some political theorists, is deliberation: the calm, reasoned, informed discussion of the pros and cons of alternative policies. Deliberation in the real world can never be purely disinterested: individuals and groups have economic and other interests and, in a capitalist democracy like that of the U.S., can be expected to organize to try to advance those interests in the public arena. But if deliberation cannot be disinterested -- if we cannot decide public policy questions behind a Rawlsian 'veil of ignorance' in which no one knows his or her particular socioeconomic position -- we nonetheless can, or at least we should, expect deliberation to adhere to certain minimal standards of civility and intelligence.

Public debate, of course, has often departed from such standards. To stick with the U.S. context, personal invective and ad hominem attacks have been a feature of American politics from the beginning. The Federalists and the anti-Federalists often attacked each other in the vilest terms imaginable, as did, especially somewhat later on, the proponents and opponents of slavery. The dispute over the Bank of the U.S. in Andrew Jackson's administration was hardly a model of temperate discussion. Many other examples could be given. Reasoned deliberation, purged of emotionalism and personal accusations, is a liberal ideal that is realized only very imperfectly in practice, when it's realized at all.

That said, it is nevertheless discouraging to observe the level and tone of debate now occurring on the subject of health care reform. The immediate occasion for this observation is my reading today of Charles Krauthammer's Wash Post op-ed and a few of the many reader comments on it. I disagree with Krauthammer's general opposition to any overhaul of the health-care system. But his specific point in this column, that prevention is not a 'magic bullet' when it comes to health care costs, is worth considering and debating on the merits. While some of the reader comments do address the merits, many others do not. Instead, they fling ad hominem charges -- a few go so far as to suggest that Krauthammer is endorsing human suffering, which he is not -- and they observe that Krauthammer has been wrong on other issues, such as the Iraq war.

Now it's true that Krauthammer was wrong on the Iraq war -- in my opinion he's been wrong on nearly every foreign policy issue of the last thirty years, or however long he's been writing his column. But that does not mean that he is necessarily wrong about the issue of prevention and costs. Some commenters point out that he underestimates the aggregate societal benefits of prevention, while others observe that his argument does not distinguish clearly between more-expensive and less-expensive types of prevention. Those commenters are contributing to reasoned debate. The commenters who hurl epithets -- "Nazi," "moron," "idiot" -- are not, any more than the people screaming and shouting at town meetings are.

The U.S. health care system, like the U.S. tax code and some other aspects of the American system, is byzantine, very wasteful, costly, inefficient. It produces excellent care for some while relegating others to second-tier treatment or none at all. As a 'developed' country with no universal or near-universal health insurance, the U.S. is an outlier. These are all obvious statements and they suggest that some kind of comprehensive reform is urgently required. I don't think myself competent to weigh in on the details of the current proposals, except to say that members of Congress should try to exercise the courage to admit that some taxes will probably have to be raised -- and not necessarily only on multimillionaires -- to fund the required reforms. Some savings can come from more administrative efficiency and competition (and maybe even from basic forms of prevention), but more taxes will still likely be necessary. I also tend to favor a public option. Beyond that, I can't contribute much to the substantive debate. But I feel that people committed to reasoned deliberation should speak up against the debased public discourse currently surrounding this issue.

Tell it, man

In a rather wild blog post (well, maybe all his posts are like this, I don't know), David Rothkopf at FP reports on a British medical study which concludes that rapid economic transitions (e.g., the ex-USSR's transition to its version of post-Communism) can be quite deadly, literally. In the course of this not-short (and, I must admit, occasionally funny) piece, Rothkopf suggests, inter alia, that Obama & Co. have replaced the bust of Churchill with a sculpture of Trotsky. Ha ha.

Mugabe's fantasy world

South Africa has declared that its border with Zimbabwe is a disaster area, while Robert Mugabe for his part has announced that the cholera outbreak in Zimbabwe is over. Perhaps tomorrow Mr. Mugabe will announce that the earth is flat -- and I don't mean in the figurative Thomas Friedman sense.

Globalization of healthcare-for-the-rich

"There is a revolution afoot in international healthcare." So begins a piece in the May-June issue of Harvard Magazine, which notes that changes in U.S. visa policy since 9/11, making trips to the U.S. for certain purposes more difficult, have prompted wealthy non-Americans to seek "world-class" healthcare outside the U.S. Hospitals for the wealthy (or relatively wealthy) have been springing up around the world, and various U.S. universities have sought to capitalize on this.

Something called Harvard Medical International (HMI), which was set up in 1994 to make money for Harvard Medical School (HMS) and which has projects in 20 countries and an operating budget (for '07) of $21 million, is being transferred by the university to Partners Healthcare, "the parent organization for two of the largest Harvard-affiliated teaching hospitals." The rationale for the transfer is that HMI is a consulting company that should never have been a formal part of the university in the first place. But the new organization will be allowed to use the Harvard name, when entering into new contracts, for the next five years, and the university will continue to be involved in some aspects of HMI-connected projects. HMS will continue to operate, for example, its Dubai Center (for postgraduate and continuing medical education), which is linked to the projected 4-million-square-foot Dubai Healthcare City.

A pertinent issue, broached but not really tackled by the article, is whether this whole trend benefits anyone other than the wealthy. If so, very indirectly, would be my admittedly ignorant guess. On the other hand, an interesting coda to the article, which may relate to this issue, questions "the model that says medical advances develop in the United States and ripple out to the rest of the world." It relates the story of an HMS student, Eric Twerdahl, who spent a summer researching "the impact of HMI projects in Dubai and India on healthcare in their respective regions." It goes on:

Twerdahl met a vascular surgeon in Bangalore who has revised operating room practice -- for example, sterilizing and reusing equipment, instead of using disposable items -- to cut the cost per procedure. He met a cardiac surgeon in Mumbai who has pioneered open-heart surgery without general anaesthesia, using instead an epidural administered above the level of the heart. These innovations sharply increase access to care, but were unlikely to develop in the United States, where the healthcare system is much less responsive to cost. In this sense, says Twerdahl, "the days of U.S. medicine thinking that it's at the top of the pile are numbered."

But at the same time, of course, that organizations like HMI are engaged in projects that may encourage such innovations, it is safe to assume that a number of health systems in various parts of the world are not at all in good shape: see, for instance, this report on the situation in what used to be Soviet central Asia.