What is Working -- Roger Bate, All Africa.com, 2007-01-22
What is Working?
East African Business Week (Kampala)
January 22, 2007
Posted to the web January 22, 2007
By Roger Bate
With a mixture of self-interest and moneymaking zeal, private businesses are combating one of the world's most intractable problems: the scourge of disease in Africa.
Some of the efforts are working, some not, and the keys to success seem to be honesty, sound science, and, of all things, the profit motive. Here's a look at three programs, all poorly understood, if known at all, by the public: attempts to combat malaria by global corporations, efforts to fight HIV/AIDS by pharmaceutical companies, and a low-cost approach to providing essential medicines.
At least one million Africans, the vast majority of them children, die each year from malaria. In Liberia, for instance, malaria is the number-one cause of death, responsible for 47% of all mortality.
Malaria is transmitted to humans by the anopheles mosquito, which is repelled by the organic insecticide DDT (dichlorodiphenyltrichloroethane).
Unfortunately, DDT was the main villain of Rachel Carson's popular 1962 book, Silent Spring, which claimed that the compound caused cancer and made the eggshells of birds dangerously fragile (thus, the book's title). Partly as a result, DDT was widely banned for agricultural use. And since its public health functions were no longer important in the United States and Europe, where DDT helped eradicate malaria and other insect-borne diseases in the 1940s and early 1950s, support for its use globally evaporated quickly.
The dangers of DDT were greatly exaggerated, and it was only last September that the World Health Organization announced that "nearly 30 years after phasing out the widespread use of indoor spraying with DDT...to control malaria," its policy had changed, and DDT "will once again play a major role in efforts to fight the disease."
The best-known partnership raising awareness of malaria in Africa is Roll Back Malaria (RBM), which includes multilateral aid agencies such as the World Bank and the U.S.
Agency for International Development (USAID) plus corporate supporters such as ExxonMobil, Novartis, and Bayer. RBM has indeed raised the profile of malaria, and it provides a way to bring businesses into the act of fighting disease, but, like other international programs of this nature, it is infested with policies often more politically correct than soundly scientific.
One of those policies is a preference for bed nets and medical treatment over indoor spraying with small amounts of DDT.
Roll Back Malaria has been described by the British Medical Journal as a "failing" program, and other objective observers, such as Amir Attaran of the University of Ottawa, writing in Nature magazine, concur.
But perhaps the best evidence that RBM's approach is mistaken is that countries that do not require aid to fight malaria (such as South Africa) totally ignore its advice. In 1998, RBM announced a target to halve malaria rates but produced no baseline data, and today the available evidence is that malaria rates have increased globally, while declining in the pockets of the world-such as South Africa, Swaziland, Botswana, Namibia, Zimbabwe, and Zambia-where internal spraying with DDT has been used.
Companies that, in their own business operations, stress tough empiricism go all wobbly in their charitable efforts if there's a risk of criticism, as there appears to be with DDT use. "But," says the British Medical Journal, "dicophane (DDT) is effective, with a remarkable safety record when used in small quantities for indoor spraying in endemic regions.
Malaria cases soared in the KwaZulu Natal province of South Africa after it stopped using dicophane in 1996.... Dicophane, a 'dirty word' in the malaria world, must surely be reintroduced into the conversation on rolling back malaria."
If I had an award to give to the business that is doing the most to fight malaria and other diseases in Africa, it would go to the mining company Anglo American plc.
The firm's operations are centered in South Africa, which has one of the few governments that champion indoor spraying.
South Africa also promotes artemisinin, the latest pharmaceutical therapy proven effective for malaria treatment.
In countries where DDT is banned for malaria control, Brian Brink, Anglo American's health director, has persisted with other available methods to combat the disease.
Anglo American's efforts are not pure selflessness.
The company's miners can't work if they are sick with malaria. But what is sadly unusual about Anglo American is that it takes the same clear-eyed approach to combating disease that it does to taking gold and copper out of the ground.
The most startling example of Anglo American's success has come in the northern copper belt of Zambia, where it shared ownership of the Konkola Copper Mines (KCM) with the government.
In the towns of Chingola and Chililobombwe, in one of the poorest areas of Africa, KCM lowered malaria rates by 75% in two years.
The death rate fell to zero. Currently, indoor residual spraying, abbreviated IRS, protects 37,000 dwellings (32,000 sprayed with DDT and roughly 5,000 with alternative insecticides) housing nearly 400,000 Zambians.
Konkola was so successful that other mines reproduced the approach, and, soon after, the Zambian government, assisted by the Global Fund to Fight AIDS, Tuberculosis and Malaria, and even the World Bank, copied the effort.
The Global Fund and the World Bank, by the way, publicized their involvement in these programs without acknowledging that it was a mining company from South Africa that started them.
BHP Billiton plc, which, like Anglo American, is a global resources company with headquarters in London, also deserves high praise for its work in Mozambique and other African nations.
The clinics that visited recently at the Mozal aluminum smelter outside Maputo in Mozambique are a model of good medical practice, using IRS and newer medicines and educating workers through a kind of industrial theater on how to prevent AIDS and other diseases.
Houston-based Marathon Oil Corporation is successfully using IRS in Equatorial Guinea, which has an especially undemocratic and corrupt leadership.
Critics want Marathon to pull out of the country, but one should ask whether companies from China and India, which would undoubtedly replace Marathon, would do as good a job combating disease as Marathon does.
Based on my experience, the answer is probably no.
In contrast to Anglo American, BHP Billiton, and Marathon, there is Bayer Crop Sciences, a division of the German chemical giant Bayer AG, which has been trying to discourage the use of DDT, using its influence as an industry representative to the Roll Back Malaria partnership.
Roger Bate, is a resident fellow at the American Enterprise Institute, is an economist whose research focuses on disease in developing nations. He has spent a total of about 18 months in Africa over the past decade on more than two dozen trips. Among his books is "Malaria and the DDT Story" (Institute of Economic Affairs), co-authored with Richard Tren. (To be continued next week)
Re-consider DDT against malaria -- Roger Bate & Mauro De Lorenzo, New Times, 2007-01-10
Re-consider DDT against malaria
Jan 10, 2007 at 08:12 AM
Malaria kills over one million children a year in Africa, more than any other disease. Last September the World Health Organisation (WHO) released new policy guidelines for malaria control that call for increased spraying of insecticides inside houses, or indoor residual spraying (IRS), and encourage the use of DDT, which is the most successful public-health insecticide ever produced.
Indoor spraying is one of the most effective methods of malaria control. It is safe for humans and the environment and is the main method used in most southern African countries. Yet despite its proven efficacy, developing countries � particularly those dependent on foreign aid � were encouraged to dismantle their spraying programmes and concentrate on using insecticide-treated nets for malaria control. Treated nets are an important component of any malaria control programme, but they cannot control the disease on their own.
In the late 1990s, South Africa suffered a disastrous malaria epidemic, largely because it stopped using DDT in its indoor spraying programme. It was only in 2000, when DDT was reintroduced, that the epidemic was brought under control. Other countries, such as Mozambique and Zambia, also restarted their indoor spraying programmes. The result has been a steady decline in malaria cases wherever indoor spraying with DDT is practised.
Rwandans should not fear DDT. It eradicated malaria from Europe and U.S. in the 1940s and 1950s. Sixty years ago over a million dwellings in America were sprayed every year with DDT to save lives. There was not a single case of harm from this spraying, nor to the hundreds of millions of people around the world whose dwellings were sprayed in later decades. America and Europe stopped using DDT after malaria was eradicated. But if an American child died every thirty seconds from malaria (as is the case in Africa), then you can be sure that America would re-introduce DDT.
Last year, the U.S. Agency for International Development (USAID) announced its $1.2bn Presidential Malaria Initiative. Having discouraged indoor spraying for many years, this new initiative is putting substantial resources into such programmes in Angola, Uganda, and Tanzania.
But while the U.S. government is getting things right, most other donors are lagging behind. Few European donors will support indoor spraying and the European Union has set the proverbial cat among the pigeons in East Africa by suggesting that agricultural exports could be turned away from Europe if DDT is used in malaria control.
These threats have been partially retracted, but some damage remains and some exporters in Uganda and Kenya still oppose DDT. We expect that Rwandan exporters are similarly concerned. They really shouldn�t be, and with sensible controls (to make sure that the small amount of DDT used is not diverted into farming) DDT will save lives and cause no loss of business. No African produce has been rejected by the EU due to DDT contamination.
Opposition to DDT remains from some extreme environmentalist groups such as Greenpeace, but many, such as the Sierra Club and South Africa�s Endangered Wildlife Trust, support indoor spraying using DDT and other insecticides. The WHO and USAID are now endorsing and encouraging what many malaria scientists and governments in southern Africa have been doing for years. Now is the time for other donors, non-governmental organisations, and the private sector to do the same. With more than a million preventable deaths every year, there is no time to lose. Rwanda�s current policies will certainly save lives. But many more lives could be saved if Rwanda adopts indoor residual spraying using DDT as part of its malaria control programme.
BY ROGER BATE & MAURO DE LORENZO
Roger Bate and Mauro De Lorenzo are resident fellows at the American Enterprise Institute for Public Policy Research in Washington, D.C.
On 19 January 2006, United States Secretary of State Condoleezza Rice announced fundamental changes to US foreign aid assistance. In an effort to promote effectiveness, the current United States Agency for International Development (USAID) Administrator, Randall Tobias, would now also serve as the first Director of Foreign Assistance. The position assumes a status level of Deputy Secretary of State, with the organization's activities and management more closely aligned with the State Department. This bold move reverses the Foreign Assistance Act of 1961, which established USAID as a separate entity. As an independent federal agency, USAID's original mandate at the height of the Cold War was twofold: to further America's foreign policy interests by expanding democracy and opening markets to American goods while improving the lives of the citizens in the developing world. Development was always a 'principal objective of the foreign policy of the United States,' as section 101 of the Foreign Assistance Act 1961 states, but played second fiddle to more obvious foreign policy concerns.
For the full text of this article, please open the attached Adobe Acrobat (PDF) file, or visit http://www.rsmpress.co.uk/USAID.pdf
Malaria initiative progresses -- Roger Bate, Washington Time, 2006-12-14
Today the White House will host its first-ever summit on malaria. It will celebrate a major change in U.S. malaria control policy and should provide the president some much needed good publicity. It is too early to conclusively prove the efficacy of enacted policy changes. But there is no doubt the Global Health Bureau of the U.S. Agency for International Development, which is making the changes, is moving foreign assistance in the right direction.
This has been quite a year for U.S. foreign aid. On Jan. 19, Secretary of State Condoleezza Rice announced fundamental changes to U.S. foreign assistance, aligning USAID more closely with the State Department. Miss Rice declared that policies were being reoriented to "build and sustain democratic, well-governed states that will respond to the needs of their people and conduct themselves responsibly in the international system." Miss Rice had already overseen acceleration in foreign assistance funding, from about $10 billion in 2000 to more than $27 billion in 2006.
But access to basic health in poor countries, a robust proxy for development, remains very low. USAID has had little to show for its efforts. Though U.S. foreign health funding has increased from about $1.6 billion in 2001 to just more than $4 billion in 2006, USAID rarely measured its performance and has often been ineffectual, notably in malaria control.
Malaria, an entirely preventable and treatable disease, kills at least a million people yearly, mostly children under age 5 and pregnant women. Prompted by anti-malaria advocates, the U.S. Congress led a series of investigations into USAID's malaria control programs between September 2004 and January 2006. These hearings found almost no monitoring and evaluation of performance, no ability to account for spending with any meaningful precision, and the promotion of poor public health and clinical practices.
Contractors could decide what information to redact from contracts, so researchers could not ascertain how budgets were spent. Of the money accounted for, most went to general advice-giving programs and consultants seemingly incapable of building sustainable local capacity. Only about 8 percent of its $80 million fiscal 2004 budget was used to purchase actual lifesaving interventions, such as bed nets, insecticides or effective drugs.
Technical advice and training play a role in sustainable development, but the agency could provide almost no evidence that programs actually helped save lives, build sustainable local infrastructures, provide effective interventions or cooperate with other agencies. USAID's measurements focused almost entirely on inputs, such as the number of nets distributed, drugs purchased or health workers trained in a certain locale, rather than outcomes (improvements in health).
Sen. Tom Coburn, Oklahoma Republican, host of several of the key hearings exploring USAID's regrettable failings, once likened the new criticisms to bursts of "sunlight" shining on the malaria program. The Senate Subcommittee hearing in May 2005, coupled with persistently unfavorable coverage in the academic and popular press, marked a turning point for the Global Health Bureau.
Yet USAID worked with the Office of the President to change malaria practices. On June 30, 2005, President Bush launched the President's Malaria Initiative (PMI), a $1.2 billion initiative to halve malaria by 2010 in 15 countries. It initially funded Angola, Tanzania and Uganda for fiscal 2006, focusing on effective management, best practices, transparency and accountability.
This initiative did not apply to regular program funding for malaria control, so six months after PMI's inception and in his final days as USAID administrator, Andrew Natsios announced momentous and largely unprecedented reforms to USAID's malaria program. The agency promised to shut down all minor programs for malaria control that spent less than $1.5 million annually. This was a welcomed change, as USAID had previously spread funds too thinly. While half its fiscal 2005 budget was spread between 21 African country-level programs and 3 regional offices, more than two-thirds of its fiscal 2006 budget went to 17 African countries and one regional office.
USAID also promised to allocate nearly half of its budget to buying commodities, such as bed nets, insecticides and effective drugs. At the close of fiscal 2006, USAID's malaria program is achieving many of its targets.
One key problem remains. There appears to be no effort to disengage USAID from supporting large Beltway contractors, often with little competition in contracting. This is hard to square with USAID's stated commitment to build country capacity and foster sustainable development.
But this problem should not stop the White House celebrations today. Fewer children have malaria because of the President's Malaria Initiative and in this festive season, I for one, will drink to that.
Roger Bate is a resident fellow of the American Enterprise Institute of Public Policy Research.
Corrupting Health -- Roger Bate, TCS Daily, 2006-11-28
By Roger Bate: 28 Nov 2006
GUATEMALA CITY -- Transparency International (TI) celebrated its 12th International Anti-Corruption Conference (IACC) last week in Guatemala.
Founded by ex-World Bankers and influential government officials from developing countries such as Kenya and Bangladesh, TI , which is one of the more effective and sensible global NGOs, has pushed the World Bank as well as increasing numbers of Governments to address corruption seriously.
Over 100 countries were represented at the conference; many of the delegates risk their livelihoods, and a few their lives, by fearless denunciation of corruption at home.
Dr. Ana Cecilia Magallanes Cortez from Peru was awarded the 2006 Transparency International Integrity Award at the opening ceremony. Dr. Magallanes, a fearless anti-corruption fighter, overcame enormous personal dangers to lead the force that successfully prosecuted 1,500 members of the criminal organization of General Vladimiro Montesinos, the collaborator of former president Alberto Fujimori. Unfortunately others couldn't be recognized; Christian Mounzeo an anti-corruption activist from Congo-Brazzaville was arrested at home before he could travel to the event.
Corruption is usually defined as the use of public office to further private gains, so the conference and analysis focused on the important areas of defense and the arms trade, money laundering, extractive industries and infrastructure. But healthcare is taking up more and more of government budgets globally and corruption is probably rising faster in healthcare than almost any other sector.
This a problem not just in poor countries but all over the world. Roy Poses, a medical professor from Brown University, described conflicts of interest, ethical concerns and occasional fraud in America. Fortunately, major corruption is estimated to be low in the US in the health sector.
Corruption in the health sectors of the poorest countries is high. A greater asymmetry of information between the professional (the doctor or hospital administrator) and the layman (patient) than in wealthy countries opens all sorts of opportunities for being prescribed the wrong treatment and procedures, or at least inappropriate billing.
Absenteeism and 'phantom employees' are major problems in clinics and hospitals. Maureen Lewis of the World Bank notes "among the most serious issues in developing countries is the high rate of absenteeism, which undermines service delivery and leads to closed public clinics that compromise the equity and health objectives of publicly financed health care." Absenteeism rates in the health service delivery are alarmingly high: 60 percent among physicians in one surveyed Dominican Republic hospital, an occurrence which is mirrored in other places such as Bangladesh and Uganda. In Uganda, for example, health workers are often found at home or involved in second jobs when they should be doing their primary job. Such routine corruption and disregard of oversight mechanisms take on even graver significance in emergencies when efficient medical care is most critical.
The increasingly large and legal market for pharmaceutical drugs is attracting criminal activity. Pharmaceuticals are high value and easily portable, and the penalty for stealing or smuggling them is far lower than for narcotics, so trade is brisk. This is especially the case in Africa where borders are porous to those prepared to pay bribes. Furthermore pharmaceutical markets are segmented internationally since companies recouping research and development costs want to charge efficient prices in vastly different settings for products with very low marginal costs. Antiretrovirals (ARVs) to treat HIV have 20-fold price differentials between western and African countries, which mean illegal but massive arbitrage possibilities exist for smugglers.
Botswana had a problem with the ARVs in its domestic AIDS treatment program. According to several Botswanan delegates a small proportion of these ARVs were being sold by non-Botswanan southern Africans into the markets of Zimbabwe, Namibia, Mozambique and South Africa. The southern African expatriates working in Botswana's health system had access to the drugs and decided to sell them in their local home market. Better management of drug procurement, storage, dispensing and other general monitoring systems are being put in place to address the problem. And while such problems were not widely discussed in the media, they were addressed by the increasingly open Botswanan Government.
Given my own research interests it was great to see TI endorse the notion that medical taxes should be lowered because they restrict access to essential medicines: "TI can improve access to medicines and lower corruption by pushing countries to lower their medicinal tariffs." This will also boost trade and lower drug prices through increased competition. India recently lowered its drugs tariffs, which encouraged US drug company Gilead to enter the Indian market to sell its brand name ARV Viread. This forced Cipla to lower the price of its legally produced copycat version.
Eradicating corruption from the health sector through the removal of tariffs, and other import duties is vital yet it is unpopular with bureaucrats and often donors, who simply don't want the problem discussed, wishing it would disappear. It will not. Transparency International should be commended for investigating and bringing attention to corruption in health. Reducing this type of corruption in poor countries will probably do more for the sick than all aid put together.
Roger Bate is a Resident Fellow of the American Enterprise Institute.
Malaria: no time to pass the buck -- Richard Tren, Business Day, 2006-11-22
Malaria: no time to pass the buck
THIS week, Southern African Development Community (SADC) countries are marking Malaria Week by holding a ministerial conference in Namibia. The theme of the conference is Scaling up Indoor Residual Spraying (IRS) with DDT. IRS involves spraying small amounts of insecticide inside houses and although it is highly effective in malaria control, it was shunned by most donors and for years. It was also discouraged by the World Health Organisation (WHO) to avoid environmental and political scorn, not for scientific reasons. Now the tide has turned and the emphasis on IRS is encouraging. However, SADC and other African countries have to get a lot more right before they can beat malaria.
The prospects for malaria control have improved recently. Earlier this year the WHO explicitly endorsed the use of DDT for malaria control and the US Agency for International Development has now, for the first time in more than a decade, purchased DDT for malaria control in Africa. New long-lasting insecticide-treated nets are being bought and distributed throughout the continent. The price of the new highly effective artemesinin-based combination therapies for treating malaria has been falling and more countries are making these drugs available. We are now closer to a viable, effective vaccine than ever before, though it will be several years before the best candidate is available.
Yet every day hundreds of people still die from malaria. The policies for malaria control have improved, but financing and managing malaria control lags. Recently, the Global Fund to fight AIDS, TB and Malaria announced the results of the round 6 applications for funding to fight these diseases. While more TB projects were funded than ever before, fewer than a third of the applications for malaria control projects were funded. The Global Fund�s technical review panel noted that good technical assistance from the WHO and the Stop TB partnership to applicant countries was a primary reason for the success of TB applications. Poor technical assistance from the UN-led Roll Back Malaria partnership (RBM) accounts for the paltry funding of malaria projects.
At a recent RBM Partnership meeting in Geneva, the partners recognised their failure and pledged to do better for the next round of Global Fund applications. Ensuring that RBM provides useful technical assistance is essential. Perhaps more important will be to ensure that the WHO�s Global Malaria Programme is well funded and able to support malaria programmes around the world. Since taking control of the programme, Dr Arata Kochi has improved malaria control policies by providing much-needed leadership. The WHO is the world�s premier public health policy organisation and it is appropriate that Dr Kochi�s department provides technical assistance to member countries.
Ultimately, however, responsibility for malaria control must rest with malarial countries, and the same is true for all health problems in poor countries. In April 2001, African heads of state met in Abuja, Nigeria, and among other things pledged to devote at least 15% of their total national budgets to improving health care. The heads of state also called upon donor countries to increase assistance for disease control. According to the WHO�s World Health Report 2006, only one country, Liberia, has achieved the 15% target. Many public health advocates, myself included, wish to see increased resources to fight malaria as the disease is considered to be a good public health investment � for a relatively small investment, many lives can be saved. But the hypocrisy of African countries pleading for more funds for disease control when they themselves do not prioritise health care persists.
Malarial countries should step up their own support for malaria control not only to look good for donors, but because funding that is detached from donor agency strings can lead to better malaria control. One of the reasons that SA maintains a successful malaria control programme is that it introduced DDT spraying and new effective drugs years before the various United Nations organisations and donors endorsed them. Independent funding ensures that local malaria scientists are better able to implement policies that are correct for their needs. Increased local funding will also guard against fickle donor agencies that may well withdraw funding when they become tired or bored with malaria control.
We can and should expect more from African countries and should hold them to the pledges they make. Anything else would smack of what US President Bush once termed the �soft bigotry of low expectations�.
‖Tren is a director of Africa Fighting Malaria.
Lady Madonna, Children At Your Feet -- Richard Tren, TCS Daily, 2006-10-26
Yohane Banda, the father of Madonna\\\'s newly adopted son, David, has thanked the pop diva for rescuing his son from \\\"poverty and disease.\\\" However recent news reports have suggested that Mr. Banda was not fully aware of the implications of the adoption and that he would prefer to have his son nearby where he can see him and be able to take him back when his circumstances improve. The whole affair raises many questions about the role that westerners should play in helping Africa to develop. It also raises questions about the role of high profile celebrities that have taken on African causes - the current track record of celebrity Africa-philes leaves much room for improvement.
Madonna currently funds six orphanages in Malawi and according to the BBC she has plans for another orphanage that will care for 4000 children. Whether Madonna has shown an interest in African orphans as a result of some new found Chabalistic spirituality or simply out of a natural human instinct to want to care for those less fortunate than herself is neither here nor there; children in Malawi are probably better off for her help. Certainly David Banda will be materially better off and his health will undoubtedly be better; wherever Madonna takes him, he will have safe drinking water, plenty of food and will not be bitten by deadly Anopheles mosquitoes.
But there are several other things that Madonna could do to improve the lives of ordinary Africans - and it wouldn\\\'t involve adopting the entire continent. For a start she could lend her support to the World Health Organization\\\'s new policies on malaria control. David Banda\\\'s two siblings both died of malaria, joining more than a million young Africans that succumb to the disease every year. The WHO is now calling for increased indoor spraying with insecticides such as DDT. Even though this method of control is safe for humans and the environment, many environmentalists continue campaigning against it. A timely message from Madonna on the topic might help convince people that it makes sense. It is depressing that people would sooner believe a celebrity on this topic than scientists, but welcome to the 21st century.
And if really cares about Africans, she can go much further. Depressingly, Malawi is one of the least free economies in the world. According to the Fraser Institute\\\'s Economic Freedom of the World index, Malawi is ranked 116 out 130 countries. With the exception of a handful of countries, almost all of the least economically free countries in the world are in sub-Saharan Africa. It is little wonder then that while most of the world has been growing richer, enjoying improved health and increased life expectancies, African countries have been in reverse.
David Banda will certainly grow up healthy and well educated, but what is less certain is whether he will want to return to Malawi. At a recent forum at the Cato Institute in Washington DC, Ugandan journalist and political commentator Andrew Mwenda pointed out that educated Africans were abandoning Africa out of sheer disgust with the political leaders that have presided over the continuous impoverishment and desperation of the continent. So if David Banda turns out like other educated Africans, including this author, he will prefer to remain in the West where he can achieve more and develop his full potential.
Andrew Mwenda is uncompromising in his criticism of African leaders and unwavering in laying the blame for Africa\\\'s trouble at their feet. Yet he is also uncompromising in his criticism of western governments that have continually funded bad governments in Africa. Much donor aid and World Bank loans have exacerbated and perpetuated poverty in Africa by giving governments entirely the wrong set of incentives. Donor aid and World Bank loans reward the incompetence and corruption of the political elite. As long as African leaders maintain economic policies that frustrate private enterprise and wealth creation, they will always be able to get donor aid, to which they are addicted. It is much harder to raise government revenue from a domestic tax base, which would require the hard work of economic reform. Ensuring that African governments are more self-sustaining would mean that they would actually have to answer to their own citizens; something that history shows they are loathe to do.
Madonna is probably the most versatile pop icon. She has reinvented herself time and again and expertly always gives her fans exactly what they want. Madonna is a classic iconoclast and never seems to shy away from controversy. She now has an outstanding opportunity to attack the current wisdom on donor aid. She could use her power to take on the \\\"aid bwanas\\\" and her celebrity colleagues.
For the sake of millions of Africans, let\\\'s hope she takes the celebrity path less traveled and actually does something helpful for ordinary Africans and not something helpful for the elites that rule Africa. Her publicists and advisers may argue against this, but being a mother carries with it certain responsibilities. If she takes her role seriously and wants David Banda to return to a country worth living in, she would do it.
Richard Tren is a director of the health advocacy group Africa Fighting Malaria and is based in Washington DC.
Light at end of malaria tunnel -- Richard Tren, Business Day, 2006-09-18
Posted to the web on: 18 September 2006
Light at end of malaria tunnel
MALARIA has the dubious honour of being the number one killer of African children, even though it is a preventable and curable disease. Expert estimates figure that malaria kills more than a million people around the world each year, with 90% of deaths in sub-Saharan Africa and most of those among young children and pregnant women. Efforts to control the disease have been patchy, with successes in some countries and failures in others. Part of the problem has been poor leadership from the World Health Organisation (WHO) and its partners in the Roll Back Malaria partnership formed in 1998. This was supposed to halve the burden of malaria by 2010, yet by some estimates the burden has been increasing.
Thankfully things are changing. In January the WHO released new malaria treatment guidelines and on September 15 it released new policy guidelines on insecticide spraying for malaria control. The new policy calls for increased spraying of insecticides inside houses, or indoor residual spraying (IRS), and encourages the use DDT, which is arguably the most successful public-health insecticide yet produced. IRS is one of the most effective methods of malaria control. This form of disease control is safe for humans and the environment and is the main method of control for many southern African countries.
Yet despite its proven efficacy, for many years malarial countries, particularly those dependent on donor aid, were encouraged to dismantle their spraying programmes and concentrate rather on using insecticide-treated nets for malaria control. These nets are important in malaria control, but have yet to demonstrate that they can control the disease on their own.
Various reasons are given for discouraging IRS, such as misplaced concerns about environmental impacts. But the most persistent claim is that IRS is logistically too complicated and expensive to conduct and therefore unsustainable. Yet denying IRS funding because it is too expensive simply resulted in a convenient self-fulfilling prophesy � IRS would remain unsustainable as long as donors and the WHO denied it funding and discouraged it.
In the late 1990s, SA suffered a disastrous malaria epidemic, largely because it stopped using DDT in its IRS programme. Resistance to the replacement insecticides meant that IRS became cosmetic and ineffective. It was only in 2000, when DDT was reintroduced, that the epidemic was brought under control. Other countries, such as Mozambique and Zambia, also restarted their IRS programmes. The result has been a steady decline in malaria cases wherever IRS is practised. These experiences have shown that IRS is sustainable if governments and donors choose to make it so.
Last year, the US Agency for International Development (USAID) announced its $1,2bn President�s Malaria Initiative. Having discouraged IRS for many years, this new initiative is putting substantial resources and efforts into IRS programmes in Angola, Uganda and Tanzania. Following pressure from congress, USAID will be measuring the effect of its malaria spending, so that we will be able to see whether its various interventions are reducing malaria cases and deaths.
This along with WHO�s latest endorsement and encouragement of IRS means that prospects for malaria control are improved. Not only is there more money for malaria control, but the policies are improving too.
It is no coincidence that the new head of WHO�s Global Malaria Programme and the driving force behind the reforms to malaria control policy, Dr Arata Kochi, released the new policy in Washington. For while the US government is getting things right, most other donors are lagging behind. Few European donors will support IRS and the European Union has set the proverbial cat among the pigeons in east Africa by suggesting that agricultural exports could be turned away from Europe if DDT is used in malaria control. These threats have been partially retracted, but the damage has been done and now exporters in Uganda and Kenya vehemently oppose IRS using DDT.
Opposition to DDT remains from some environmentalist groups such as Greenpeace, but many, such as the Sierra Club and SA�s Endangered Wildlife Trust, support IRS using DDT and other insecticides.
The WHO and USAID are now endorsing and encouraging what many malaria scientists and governments in southern Africa have been doing for years. Now is the time for other donors, nongovernmental organisations, and the private sector to do the same. With more than a million preventable deaths every year, there is no time to lose.
‖Tren is a director of the health advocacy group Africa Fighting Malaria.
Medicine tariffs: how they cost lives -- Richard Tren, Business Day, 2006-08-10
Medicine tariffs: how they cost lives
HARRY Lime, the odious character played by Orson Welles in the 1949 film The Third Man, is a man most people would happily hate. This seedy racketeer sold adulterated penicillin to the poverty-stricken population of postwar Vienna, something which must rank as one of the more objectionable crimes. It is particularly heinous when one considers that many poor people will save up and sacrifice other goods in order to buy �medicines�. Yet in many countries, governments sink as low as Harry Lime by creating barriers to obtaining medicines, passing rules and regulations that delay delivery, imposing tariffs to hike prices, and creating perfect conditions for officials to extort bribes.
A new study published by the American Enterprise Institute calls for an end to tariffs on medicines and to the corruption that often accompanies them. The study, of which I am a co-author, details the results of surveys of various organisations from the private and public sectors as well as charities involved in importing medicines and medical devices to developing countries.
Respondents, most of whom preferred to remain anonymous, reported that in 85% of cases, their products experienced unanticipated delays in clearing customs � sometimes delays of a few days, but often of many months. The worst performing country with regard to delays was found to be Nigeria, followed by Kenya and India.
The mere fact that some countries impose import tariffs on medicines and the complexity of the tariff rules means that customs officials have an ideal opportunity to exact bribes from medicine importers. In one-third of the cases, respondents reported that an out-and-out bribe was demanded from customs officials in order to clear their goods.
Delays are possibly the most damaging aspect of the corruption. In some cases, sensitive medicines are held up at border crossing and because they require specialised storage, they are spoiled. The import tariffs, the bribes and the lengthy delays all hamper public health efforts in countries often facing severe health emergencies. With diseases such as malaria, the delays can cost lives. Many countries have a defined malaria season and mosquito control efforts have to begin before the rainy season begins and the mosquitoes begin to breed. Any delay in delivering insecticides, mosquito nets or medicines means more mosquitoes, and therefore more people exposed to their deadly bite, and little in the way of treating them when they become ill.
Interestingly, our study finds that most donor-nation disease-control programmes, such as those run by the US Agency for International Development, are not subjected to the delays and corruption that others face. The strong diplomatic and economic pressure that the US government can exert means that few countries dare interfere with official development aid.
Most charities, nongovernmental organisations and private companies involved in health care don�t have the benefit of protection against this bureaucratic bullying. A recent study by the Washington-based Hudson Institute showed that, overall, US private international donations to developing countries exceeded $62bn in 2003, more than three-and-a-half times the official donor aid from the US government. This private aid from well-meaning individuals in the US is sent in the hope of relieving suffering in poor countries and yet it seems that state officials rather view it as a way to line their pockets.
Developing countries have it within their powers to stop the corruption and absurd barriers to trade that keep their people locked in poverty and exposed to avoidable and curable diseases. Poor-country governments can and should remove all tariffs or charges imposed on medicines, medical devices, insecticides and other public health products. Giving tariff exemptions
to certain organisations or certain disease classes is not good enough as it simply creates complications that allow customs officials to tie products up in red tape and extort bribes. The only way to rid a country of corruption is to remove the discretionary power of officials to extort bribes. If everyone knows that there are no tariffs, officials won�t be able to use the threat of them in order to be paid off.
Several World Trade Organisation member countries already have an initiative under way that would remove all medicine import tariffs; poor countries could easily sign up to this. Any failure to make these necessary reforms equates to tacit approval of corruption and official countenance of the fact that millions go without accessible medical care.
‖Tren is a director of the health advocacy group, Africa Fighting Malaria.
Drug Snares -- Roger Bate & Kathryn Boateng, National Review Online, 2006-08-09
August 09, 2006, 0:47 a.m.
Tariffs on drugs take their toll in poor nations.
By Roger Bate & Kathryn Boateng
Throughout the developing world, hospitals have become places where patients don�t bother to go; it�s not that they aren�t sick � there just are no drugs for the doctors to prescribe for them. Two thirds of the world�s population and 80 percent of Africans do not have adequate access to drugs. While manufacturers� pricing and grotesque poverty-levels are partly to blame, a major culprit is the governments of these poor countries, which impose tariffs, taxes, and customs duties on imported drugs. This is allegedly done for the sake of protecting domestic industries, but it is actually just another way of raising funds. Some countries, such as Nigeria, Iran, and India, have tariffs of over 15 percent, which, combined with other charges, increase the prices of some drugs by more than 50 percent. Not only do these price increases make drugs more scarce, but they also encourage corruption, and with fatal consequences, as we explain in our paper published today.
Last month, confronted with compelling issues of global security and energy prices, G8 leaders still managed to set aside the time to denounce the severe public-health effects of tariffs on medical interventions in their final communiqu�: �We encourage governments around the world to consider eliminating import tariffs and non-tariff barriers on medicines and medical devices, where appropriate, as a measure to reduce further the cost of health care for the poor and expand their access to effective treatments.�
And at last year�s G8 summit in Gleneagles, world leaders identified eliminating corruption as a key component for establishing the necessary conditions for economic growth in poor nations. In our latest research, we analyzed the link between tariffs and corruption and found evidence that tariffs provide opportunities for irregular payments and delays of product shipments.
The paper is the product of months of interviews and surveys in the field, providing us with first-hand accounts of experiences with drug delivery in developing countries from charitable, corporate, multilateral, and bilateral aid agencies. Most respondents reveal that tariffs on essential medicines are a �serious threat� to access to medicines. We found numerous instances in which organizations donating products were asked to pay questionable �administrative handling� fees and other �custom support� fees. In one case, donated drugs destined for use in South Africa were repeatedly delayed because of several bureaucratic requirements which took years to resolve, and only after the donor secured the services of appointed local distributors. The frustration of many philanthropic drug-donating organizations was succinctly expressed in one interview thus: �The necessity to invest both time and effort to address such delays is a significant deterrent to [our] ongoing commitment.�
But the pernicious effects of tariffs on the availability of essential medicines permeate deeper still. The burden caused by high and frequently altered tariff rates creates an opportunity for public officials to extract bribes; since local officials often have asymmetric knowledge about what is a correct fee, as well as the authority to charge it locally, this allows them all sorts of leverage, such as allowing them opportunities to waive official fees if paid a bribe. Also, random or capricious intervention by customs officials makes criminals of importers by often leaving them little choice but to pay bribes to avoid delays, especially where goods with short shelf lives (for example, antibiotics that need refrigeration) are concerned. Such corruption contributes to the instability of access to medicines in a country. Clearly, the corrupting influence of tariffs is detrimental to any ongoing efforts to improve health in a nation.
Among the specifics we found our survey are the following: Vietnamese officials routinely demand bribes; delays and unofficial administrative payments are routinely demanded in Nigeria, and it is almost as bad in Uganda, Kenya, and Ethiopia. Also, in about a third of the cases we studied (36 out of 105), bribes were demanded; and in 85 percent of the cases, delays occurred and non-official payments were demanded.
Tariffs and taxes on essential medicines account for a negligible contribution to national income, and thus are of little benefit to the governments of developing countries; the effect of the conditions they create, however, is disproportionate and damaging. Today, rallying behind the G8 are other multilateral initiatives � such as the United States Trade Representative (USTR) and the Swiss and Singaporean collective initiative to remove tariffs on essential medicines � striving to bring the era of tariff imposition on essential medicines to an end.
Leaders of developing countries should not wait for U.S. and EU action, but should restart the Doha Development round by taking the simple, initial step required to help their own people � implementing national tariff policies that eliminate tariffs and taxes on essential medicines. This action will come at little cost to their revenue base, and will bring about an immeasurable gain for their people.
� Roger Bate is a resident fellow of the American Enterprise Institute. and Kathryn Boateng is a research assistant at AEI. Their paper on the issue was published earlier this week.
A Transparently Terrific Bill -- Dr Roger Bate, The Washington Post, 2006-08-08
A Transparently Terrific Bill
By Roger Bate
Special to washingtonpost.com's Think Tank Town
Wednesday, August 9, 2006; 12:00 AM
What do Friends of the Earth, the Family Research Council, Phyllis Schlafly and the National Gay and Lesbian Task Force have in common? If you think not much, then you are partially wrong: They all love the new Federal Funding Accountability and Transparency Act. Introduced by senators Tom Coburn (R-Okla.) and Barack Obama (D-Ill.), the bill requires the Office of Management and Budget to establish and maintain a single public website listing the names and locations of all individuals and groups receiving federal funds, including the amount of federal funds received annually by program.
The idea of a transparency website -- replete with search engines that include subcontractors -- was born in May 2005 at a hearing on U.S. efforts to combat malaria. Officials from the U.S. Agency for International Development (USAID) squirmed as Coburn revealed that 93% of the agency's 2004 funding to eradicate malaria had been spent on administrative and advice-giving services. In addition, not enough of these funds were spent overseas; too much was absorbed by high-paid U.S. consultants.
Coburn, a doctor with a long record of monitoring international health spending, is fed up that U.S. tax dollars are being wasted. And so are a myriad of other individuals -- even those with normally diametrically opposed agendas. "Sunshine's the best thing we've got to control waste, fraud and abuse," Coburn says. "It's also the best thing we've got to control stupidity. It'll be a force for the government we need." Whether your pet concern is Halliburton in Iraq or the Academy for Educational Development's (AED) work in Africa, transparency will lead to more accountability.
In the case of USAID's efforts to fight malaria in Africa, the oversight returned quick results: "Once the agency figured out how they actually spent money, they couldn't justify the status quo and we saw dramatic reform," according to Coburn. "Now, lives are being saved in Africa because of USAID's malaria program. The hearing was a case study in how forcing transparency in government really can work miracles and save lives."
Congress's effort to break the bureaucratic triple threat -- too little competition, too little transparency, too few metrics to measure performance -- is long overdue. A recent Government Accountability Office (GAO) report on Hurricane Katrina spending showed between $600 million and $1.4 billion in improper and potentially fraudulent individual assistance payments. And that is just in our own country.
Audits of foreign spending are few and far between, and infrequent reports from the GAO often raise concerns of workforce planning limitations (i.e., workforces not being competent enough to integrate with the people on the ground to use taxpayer dollars effectively) as well as the need to improve oversight of organizational activities. Such limitations suggest that the problem of aid mismanagement pervades American action around the globe.
Aid-giving is a tough, gut-wrenching business, and the demands to spend for the sake of spending are constant. Without accountability, aid-giving bureaucrats often buckle under pressure to open the spigots, success be damned. Theoretically, private and for-profit contractors are meant to bring market-style efficiency, attention to the bottom line and new technologies to lower chances of fraud. Instead, bureaucrats and the private sector are bedfellows that oppose transparency. One reason for this comfortable relationship is that so many bureaucrats (from government agencies and Capitol Hill) move on to high-paying jobs with contractors because they know how to "win" contracts from their former bosses.
It is therefore no surprise that few of the largest government contractors support the Coburn bill. The long list of bipartisan nongovernmental organizations (NGOs) backing Coburn does not include any of the largest contractors, such as the AED, Chemonics International, Population Services International, Halliburton, Lincoln Group, Booz Allen Hamilton, Sprint, BearingPoint, Anteon, General Dynamics, Lockheed Martin, Raytheon, and SRA International.
Proponents of the bill suspect that companies accustomed to feeding at the government trough will band together to deep-six the Coburn initiative. Barring outright opposition to the bill's passage, the best hope for contractors is to promote a weak substitute. Remarkably, Representative Tom Davis (R-Va.), whose district includes such contractors among his most affluent constituents, has given them just the vehicle. Davis introduced a House version of the Coburn Bill, minus the transparency requirement for contractors, leaving only grant-recipient NGOs like Doctors Without Borders in the crosshairs. Representative Davis told the New York Times that "contracts are awarded in a much more competitive environment" and grants "are more susceptible to abuse."
The problem is that abuse -- whether by contract or grant -- is integral to the current system of aid. The time has come to shine light on the revolving door between government and contractors; to shine light on the corruption and inefficiency; to shine light on how taxpayer money is being spent. A little transparency will go a long way in benefiting Americans and the beneficiaries of their generosity overseas.
Roger Bate is a resident fellow at the American Enterprise Institute for Public Policy Research and a director of a health advocacy group, Africa Fighting Malaria (which supports the Coburn bill). In May 2005, he testified at a hearing on USAID's malaria program, which was chaired by Senator Coburn.
� 2006 Washingtonpost.Newsweek Interactive
Tariffs Corruption And Other Impediments To Medicinal Access In Developing Countries: Field Evidence -- Richard Tren, Medical News Today, 2006-08-06
Tariffs Corruption And Other Impediments To Medicinal Access In Developing Countries: Field Evidence
Main Category: Aid / Disasters News
Article Date: 06 Aug 2006 - 11:00am (PDT)
Lengthy customs procedures, onerous bureaucratic hurdles and tariff related corruption at borders are highlighted as barriers to accessing medicines in a new report published by the American Enterprise Institute. The report �Tariffs, Corruption and Other Impediments to Medicinal Access in Developing Countries: Field Evidence� presents evidence from interviews conducted with various organizations involved in supplying medicines and medical devices to developing countries.
As lead author, Dr Roger Bate of the American Enterprise Institute notes �we know that tariffs and taxes increase the cost of medical treatment in poor countries, but our study exposes the degree to which the delays and corruption associated with tariffs undermine healthcare and public health programs.� Bate and the co-authors go on to call for countries urgently to remove import tariffs and to simplify customs procedures so that urgently needed medical supplies can be delivered promptly.
The study finds that 85% of reported cases of importing medicines and medical devices experienced unanticipated delays, ranging from a few days to several months. Some of the cases resulted in legal expenses to free goods from customs, but in 90% of the cases, a non-official payment, such as an administrative fee, was charged and in one third of the cases a bribe was demanded from customs officials. Non-official payments and bribes increase the cost of delivering much needed medicines and medical technologies and discourage trade and healthcare aid to some poor countries. According to the study, bribes are demanded most routinely in Vietnam and least in China and Uganda. The worst performing country with regard to unnecessary delays was Nigeria, followed by Kenya.
The study finds that most official aid from donor governments is exempted from tariffs and political pressure from donor country missions can ease the flow of medical aid through customs. However, charities, faith based organizations, private companies and NGOs do not have the political clout or influence to avoid these highly damaging trade barriers.
Roger Bate argues that any customs delays can be disastrous not only because patients are forced to wait for their medicines or could be denied treatment altogether, but in some cases medicines that require cold storage are stored incorrectly, effectively destroying the shipment.
According to Richard Tren, co-author of the study and director of Africa Fighting Malaria, �the delays can often be disastrous for malaria control programs. In those countries with seasonal malaria, it is essential that malaria control activities begin on time, before transmission begins. The delays caused by corrupt, venal government officials hamper public health programs and may well lead to unnecessary deaths.�
Tren goes on to argue that �the discretionary power given to customs officials must be removed. They have no right to deny people access to healthcare and essential medicines. It is incumbent on poor country governments to remove the tariffs and any other regulations that allow this corruption to take place. The politicians that maintain these tariffs and give power to corrupt border officials are as guilty as the customs officials that receive the bribes.�
The removal of all tariffs on medicines and medical devices has been the focus of a World Trade Organization sectoral initiative, led by the United States, Singapore and Switzerland. The authors argue that despite the recent collapse of the Doha Development Round, WTO members should still pursue the worthy goal of freeing medicines from import tariffs and the corruption that often accompanies these charges.
Bill Gates must set priorities -- Roger Bate, The Australian, 2006-08-03
Spending $60 billion on health is a tough order, writes Roger Bate
August 03, 2006
WITH Warren Buffett's largesse added to his own, Bill Gates has about $60 billion to spend on health and development. How should he spend it?
The Copenhagen Consensus, a group and process put together by Danish academic and world renowned sceptical environmentalist Bjorn Lomborg, answered this question last year. Experts on the best life-saving interventions in various fields reached a consensus on what provided the best bang for the buck if they were spending $50 billion. Their conclusions could be of use to Gates.
Top of the list of value for money aid investments was combating HIV-AIDS. Improving nutrition, opening up trade, preventing malaria and improving clean water delivery were some of the next best interventions.
The Bill and Melinda Gates Foundation should be commended for supporting HIV and malaria clinical research. However, it has avoided dirtying its hands by staying away from interventions on the ground - such as drug delivery, spraying insecticides to kill mosquitoes or running bed-net distribution and support programs - that would save lives today.
Furthermore, although vaccine research is important, vaccines for HIV and malaria are still a mirage and it should be remembered that there are millions who do not receive much-needed and widely available vaccinations for other ailments.
Indeed, the Gates Foundation, as with most aid agencies, has done little in any of the areas of prioritisation identified by the Copenhagen Consensus. Aid agency chiefs, subject to the whims of politicians, who are under pressure from increasingly powerful interest groups (such as specific disease/country proponents), will never say that disease/country/approach A should take priority over the equivalent B, even if the case is obvious. In short, aid agencies often behave as though ignorant of basic economics, not optimising scarce resources to save the most lives.
Lomborg's exercise has contributed greatly towards forcing the aid community into prioritising programs.
Importantly, many programs considered successful have been driven endogenously by poor country governments or the private sector, whereas many aid programs are not (or no more than rhetorically) endorsed by recipient governments. New aid announced at the G8 summit last year, as well as new money from Gates, must be properly targeted. Without full endorsement, provision of aid usually fails, as has been repeatedly demonstrated, most recently in The White Man's Burden, William Easterly's masterful book on the limits of aid.
Gates must also realise that aid flows reflect the cost of providing services for the poor, not the value of those services. As Easterly says: "Would Microsoft Corp promote an executive who bragged about setting a record for costs? Would Berkshire Hathaway invest in a business that headlined its remarkably high spending on office supplies? Unfortunately, the foreign aid business has a sad history of bureaucrats under heavy pressure to spend money on foreign consultants and four-wheel-drive vehicles but with zero pressure to find out whether that spending translates into the forever elusive 'technical assistance', 'capacity building' and 'civil service restructuring' that are supposed to help the poor." Gates's challenge - much harder in foreign aid than in business - is to make sure his final customers are satisfied.
The customers are the poor population, not government officials. Gates, similar to so many Western governments, has given money to poor country governments and inadvertently made them less accountable to their populations. Take Uganda, where about half of government revenue comes from aid.
As Ugandan political commentator Andrew Mwenda has explained, with more and more aid the Ugandan Government has less need to look after the electorate since it needs it less and less for revenue.
Aid can encourage the nepotistic patronage system in Uganda and weaken any parts of the private sector by pushing the corrupting influences of patronage into it. So whether it's the hypothetical aid of Lomborg's exercise or the real money of Gates and Buffett, it may do more harm than good.
Perhaps, after all, Gates is well-advised to just back disease research in Western countries; at least the money is not stolen or misused. Thankfully, Gates (let's call him the G1) can be relied on to keep his eye on the ball and not be distracted when more immediate concerns arise; last year's G8-Live 8 celebrity extravaganza for saving Africa is now mostly forgotten since Africa didn't rate much of a mention at the recent G8 meeting in St Petersburg.
The G1 will likely perform better than the G8, but he still has his work cut out in finding the right interventions, funding the right groups to undertake them and not undermining fledgling democracies as he does it. It's a much tougher job than becoming a multi-billionaire and only time will tell if he's up to the task.
Roger Bate is a resident fellow of the American Enterprise Institute in Washington, DC, and a director of health advocacy group Africa Fighting Malaria. He is in Australia as a guest of the Centre for Independent Studies.
Spending Warren's Money -- Roger Bate, TCS Daily, 2006-07-19
With Warren Buffett's largesse added to his own, Bill Gates has about $60 billion to spend on health and development -- how should he spend it? The Copenhagen Consensus, a group (and process) put together by Danish academic Bjorn Lomborg, coordinated a response to this question last year. The group commissioned papers from experts on the best life-saving interventions in various fields and then reached a consensus on what provided the best 'bang for the buck' if they were to be in charge of $50 billion to spend. Their conclusions could be of use to Mr. Gates.
Top of the list of value-for-money aid investments was combating HIV AIDS; improving nutrition, opening up trade, preventing malaria, and improving clean water delivery were some of the next best interventions.
The Bill and Melinda Gates Foundation should be commended for supporting HIV and malaria clinical research. However it has avoided dirtying its hands by staying away from on-the ground interventions such as drug delivery, spraying insecticides (for malarial mosquitoes) or running bed net distribution and support programs -- all of which would save lives today. Furthermore, although vaccine research is important, vaccines for both HIV and malaria are still a mirage and one should recall that there are millions who do not receive much-needed and widely available vaccinations for other ailments.
Indeed, the Gates Foundation, like most aid agencies, has done little in any of the actual areas of prioritization identified by the Copenhagen Consensus. Aid agency chiefs, subject to the whims of politicians under pressure from increasingly powerful interest groups (such as specific disease/country proponents), will never say that disease/country/approach 'A' should take priority over the equivalent 'B' even if the case is obvious. In short, aid agencies often behave as though ignorant of basic economics; not optimizing scarce resources to save the most lives. The Copenhagen Consensus exercise has contributed greatly to forcing the aid community to prioritize programs.
The details in the Copenhagen Consensus report could be challenged in terms of project performance. Using proxy indicators can make measurements difficult. For example, bed net distribution is equated with a reduction in malaria though existing evidence shows this is a terribly flawed assumption, since many nets are never slept under. As importantly, many of the programs considered successful have been driven endogenously by poor country governments or the private sector; whereas many aid programs are not (or no more than rhetorically) endorsed by recipient governments. New aid announced at the G8 summit last year as well as new money from Gates will be susceptible to this problem, too. Without full endorsement aid usually fails, as has been repeatedly demonstrated, most recently in The White Man's Burden, William Easterly's masterful book on the limits of aid.
Gates must also realize that aid flows reflect the cost of providing services for the poor, not the value of those services. As Easterly says 'Would Microsoft Corp. promote an executive who bragged about setting a record for costs? Would Berkshire Hathaway invest in a business that headlined its remarkably high spending on office supplies? Unfortunately, the foreign aid business has a sad history of bureaucrats under heavy pressure to spend money on foreign consultants and four-wheel-drive vehicles but with zero pressure to find out whether that spending translates into the forever elusive "technical assistance," "capacity building" and "civil service restructuring" that are supposed to help the poor. Mr. Gates' challenge -- much harder in foreign aid than in business -- is to make sure his final customers are satisfied.
The customers are the poor population, not government officials. Gates, like so many western governments, has given money to poor country governments and inadvertently made them less accountable to their populations. Take Uganda, where approximately half of government revenue comes from aid. As Andrew Mwenda, a Ugandan political commentator has explained, with more and more aid the Ugandan Government has less need to look after the electorate since it needs it less and less for revenue. Aid can encourage the nepotistic patronage system in Uganda and weaken any parts of the private sector by pushing the corrupting influences of patronage into it. So whether the hypothetical aid of Lomborg's exercise or the real money of Gates and Buffett, it may do more harm than good.
Perhaps, after all, Gates is well-advised to just back disease research in western countries -- at least the money is not stolen or misused. Thankfully, Mr. Gates (let's call him the G1) can be relied upon to keep his eye on the ball and not be distracted when more immediate concerns arise; last year's G-8/Live 8 celebrity extravaganza for saving Africa is now mostly forgotten since Africa didn't rate much of a mention at the recent G-8 meeting in St. Petersburg.
The G1 will likely perform better than the G8 but he still has his work cut out in finding the right interventions, funding the right groups to undertake them, and not undermining fledgling democracies in the process. It's a much tougher job than becoming a multi-billionaire; only time will tell if he's up to the task.
Dr Roger Bate is a Resident Fellow of the American Enterprise Institute in Washington DC and a Director of health advocacy group Africa Fighting Malaria. He has testified before US Congress several times on the misuse of foreign aid.
Africa Fighting Malaria Responds To Berkeley University Study Into DDT And Neurodevelopment In Children -- , Medical News Today, 2006-07-18
Once again media attention has been given to research that links DDT exposure to human harm. The latest study by Eskenazi et al. found a limited, perhaps transient association between DDT and neurodevelopment in children at 6, 12 and 24 months born to Mexican women who lived in California following exposure to agricultural uses of DDT in Mexico. The findings, based on a small sample population in one location, prompted the researchers to recommend that countries considering the use of DDT in malaria control should �weigh its benefit in eradicating malaria against the negative associations� found in their study. Africa Fighting Malaria rejects this conclusion and finds it both irresponsible and misleading.
During WWII, soldiers and civilians were covered in DDT to protect them from lice-born typhus, a strategy which rapidly brought epidemics under control. DDT was also used to control malarial mosquitoes in the Pacific theatre of war where it was sprayed on tents and housing. Due to these resounding successes, DDT was employed widely for malaria control after 1945 through indoor residual spraying (IRS) programs. In IRS programs, DDT is sprayed in tiny quantities on the inside walls of houses where it protects residents from mosquito bites for up to a year by repelling the insects and killing the few that enter the home. This limited, indoor spraying has saved millions of people from malaria. The use of DDT in this way is entirely different to the widespread and indiscriminate spraying of DDT in agriculture, which is now outlawed.
The research by Eskenazi et al. is the latest in a long line of studies that have attempted to find associations between DDT and its metabolite DDE and harm to human health. In the past several decades, innumerable studies have examined DDT\'s toxicity and claimed �links� between DDT and human cancers, reduced maternal lactation, pre-term births, low birth weight and endocrine disruption. The overwhelming majority of these studies has not been successfully replicated and ultimately failed to demonstrate any actual human harm. DDT is known to be minimally toxic to humans, and is classified as a �possible human carcinogen� - along with coffee, beer, peanut butter and a host of everyday comestibles - by the International Agency for Research on Cancer. DDT is exempted for public health use in the Stockholm Treaty on Persistent Organic Pollutants.
Allegations that maternal lactation is affected by DDT have little substance and seem contradicted by Eskenazi\'s research. Equally the claims that DDT causes pre-term births and endocrine disruption were not confirmed by Eskenazi\'s research. Moreover, in spite of the flurry of media activity surrounding this study, the real-world implications for the current use of DDT are very limited.
Richard Tren, Director of Africa Fighting Malaria notes, �These studies amount to little more than momentary scare stories designed to direct popular attention to unknown, hypothetical risks from DDT and to ignore the considerable and ongoing benefits of using DDT in malaria control in conjunction with mosquito nets and effective drugs. The findings of Eskenazi et al. are neither conclusive nor relevant to the use of DDT with IRS programs for malaria control.�
DDT has saved millions of lives from malaria and continues to protect millions more from a disease that causes pain, suffering, childhood impairment, economic loss ($12 billion annually on the African continent) and the deaths of over a million people globally each year. This continued failure to balance the real risks that children in malarial areas face with hypothetical risks from DDT reveals a startling lack of scientific integrity, as well as ill-conceived ideas about the economics of public health policy. The media coverage of this singular, un-replicated study begs the question of how many more children and pregnant women will die from a preventable disease as a result of yet another unconfirmed scare story?
Africa Fighting Malaria welcomes research and studies that help us to understand DDT better. However, AFM urges malaria control programs, malaria scientists and public health experts to base anti-malaria interventions on sound science and scientific evidence. Limited, un-replicated studies should have no place in decision making on DDT.
 Brenda Eskenazi PhD et al. �In Utero Exposure to Dichlorodiphenyltrichloroethane (DDT) and Dichlorodiphenyldicholorethylene (DDE) and Neurodevelopment Among Young Mexican American Children� Pediatrics Vol 118, No. 1, July 2006