No Aid for AIDS

Roger Bate | 19 Nov 2004
National Review Online
The great and the good of the health world, along with at least four African presidents, have descended on Tanzania for the United Nations' Global Fund meeting. The fund, established in 2000 to combat AIDS, tuberculosis, and malaria, has so far received over $3 billion from the wealthy nations. But presidents Yoweri Museveni of Uganda, Paul Kagame of Rwanda, and Mwai Kibaki of Kenya have joined the Tanzanian president, Benjamin Mkapa, in saying that more funds are required.

But the greatest problem in Africa is the lack of political will to both combat disease and — equally important — provide the institutional conditions for growth. Without the former, disease will never be controlled; without the latter, it will always return.

Sub-Saharan Africa has always suffered under the blight of war, famine, and disease. But — with some notable exceptions — there are more democracies and fewer wars today than in the 1980s. Indeed, since 1990 many countries have had peaceful transitions of power — a welcome novelty for the region. Food supply is generally more secure than ever before, such that a particularly bad drought in Southern Africa has led to no more than food shortages in most locations. (Except, of course, for despotic Zimbabwe — where politically driven food allocation is causing widespread starvation.)

Unfortunately, many health indicators are still moving in the wrong direction. The most dangerous diseases are less controlled today than at any time in the past 50 years. Malaria and AIDS are rampant; tuberculosis is increasing from an already high rate. Much of the blame for this lies with the inadequate attention paid to health by African leaders, some of whom have continued to deny that HIV causes AIDS, and many of whom have preferred to bolster their armies against non-existent enemies. A fair bit of the blame can also be heaped on aid and health agencies that have promoted the wrong policies: notably, advocating bed nets for malaria control at the expense of the more effective indoor DDT-spraying. As a result, over the past five years, malaria rates have increased by more than 10 percent at a time when funding for malaria has increased by over 200 percent.

Most of the fund's money is spent on AIDS prevention and treatment, and a lot of this money may be well spent. Unfortunately, we just don't know. If, in the first round of disbursements in 2002, significant health outcome statistics (morbidity and mortality changes in particular) had been collected, then we could know. But unfortunately they weren't, and so we don't. Add to this the fact that the fund was procuring anti-malarial drugs that were useless — and Indian generic AIDS drugs that may be useless and have now been recalled — and its track record is rather a mess. To its credit, however, the fund has listened to criticism, and appears to be building in outcome measurements and buying the right drugs.

And when it comes to malaria, in fact, the fund is doing the best job of all aid agencies. It is actually procuring DDT for countries that ask for it, such as Zambia. Other agencies continue to promote only bed nets and are doing everything they can to obstruct the use of DDT in Uganda. A decision was made over the summer by the Ugandan Ministry of Health to use DDT procured by the fund. But insiders I spoke with, who wish not to be named, say that overseas pressure to drop DDT use means the decision is on hold.

After complaints about the fund's early actions by U.S. Senators Gregg and Feingold, it has improved. As long as this continues and the congressional oversight remains (especially the senators' calls for outcome measurements), then it should continue to expand its work in Africa. Governments could increase funding to deliver what Africans want (drugs, insecticides, and other resources), rather than what Western aid agencies want to give them (mainly seminars and funding of "educational" programs and consultants). If they opt for the former, then we might start to see a reduction in the worst tropical diseases.

The international community has been critical of the Bush administration's decisions to buy only tested AIDS drugs and to promote abstinence for AIDS prevention, but the former certainly — and probably the latter, too — have been shown to be correct. Some critics will continue to press the administration to give more money with no strings attached, but it must keep trying to promote democratic reform — particularly property-rights reform — because without secure entitlement for ordinary people, economic growth is unsustainable.

The links between economic liberty, individual property-rights protection, and health — as demonstrated by the Wall Street Journal-Heritage Freedom Indices — are too strong to be ignored. The historic lessons of malarial control are clear, and are of direct relevance to combating HIV today. Those countries that kept malaria away after eradicating it with DDT were those that either had or developed strong property-rights systems (e.g., the U.S., Italy, Singapore). Eradication was not sustained in those without these institutions (e.g., Guyana, Malaysia).

The economic ministries of African countries know this to be the case. But the health specialists dominate the turf war to receive aid, and they naively believe that wealth will miraculously appear if disease is combated. The lesson of history is that they are wrong, but those in Arusha are not listening.

Roger Bate is a fellow at the American Enterprise Institute and a director of the health-advocacy group Africa Fighting Malaria.