This chapter explores one of the central questions development thinkers should continuously ask: “What would aid recipients do with funding if they made the decisions?”
Easterly uses the Western response to HIV/AIDS in Africa to make two key points related to this question: top-down Planners can often be woefully out of touch with the realities at the bottom, and the Western world’s fascination with AIDS treatment is economically inefficient and antithetical to doing the most good. He questions whether aid recipients would put so much emphasis on treatment at the expense of prevention or other aims.
Easterly begins with what he calls “The White Man’s Burden Paradox” (modeled off the paradox of evil); he notes that the follow three conditions cannot be all true:
“1) The White Man’s Burden is acting in the interests of the poor in the Rest; 2) The White Man’s Burden is effective at resolving poor people’s problems; and 3) Lots of bad things, whose prevention was affordable, are happening to poor people”
This seems logically inconsistent to me – the word affordable is very open to interpretation, and #1 can hold without meaning that all of the interests of the poor are being acted on – but the general point still feels about right: for areas where the West does focus, #3 still occurs far too often.
As Easterly notes here and elsewhere in the book, Western interventions to improve health are more successful than other Western interventions (for a variety of postulated reasons) – so then why was the response to the African AIDS crisis so poor? It seems that part of the issue was that aid agencies realized the potential scope of the issue but did little to attack it early; the World Bank made a $1 million grant to the World Health Organization to fight AIDS in 1988, a rounding error in its funding and basically inconsequential towards efforts to prevent HIV/AIDS.
Another possible reason is that Planners were out of touch at the top “with the tragedy at the bottom;” that they failed to appreciate the scope of the impending crisis because they were too far removed from the countries where it was fomenting. And finally, the lack of response could be due to the “Kitty Genovese Effect” – everyone expected everyone else to do something, but no one did until the crisis was full-blown.
The issue of HIV/AIDS treatment in Africa is next, and Easterly lucidly lays out the contention that “compassion is driving the fight against AIDS in Africa in a direction that may cost more lives than it saves” because money is being spent on treatment of AIDS, not prevention of HIV or other diseases. While I was aware of the basics of the argument, the specifics were totally new to me, and caused me to question my tacit support for initiatives like the President’s Emergency Plan for AIDS Relief (PEPFAR), President Bush’s $15 billion AIDS relief program passed in 2003.
Let’s start with the top-line figures. According to the book, the rough costs of various health interventions in Sub-Saharan Africa are:
- HIV/AIDS: $304 per year per patient for highly active antiretroviral therapy (HAART) – $1,500 if all costs are included
- HIV/AIDS Prevention: $1-20 per year of life saved, $20-400 per HIV infection averted
- Tuberculosis: $10 per case
- Drug-Resistant Malaria: $1 per case
- Vaccinations: “pennies per dose”
The takeaway: treatment of HIV/AIDS is about as expensive as it gets. Easterly attributes the zeal for treatment of HIV/AIDS to guilt (for not preventing the crisis when there was an opportunity to do so) and “SIBD Syndrome” (Something Is Being Done) – it’s easy to see someone improving on HAART and difficult to see someone not dying from malaria. To that end, PEPFAR actually restricted funding for prevention of HIV/AIDS to 20% of the total (with one-third of that going to abstinence-only programs) – showing that Western leaders often fund their own goals, not those of the people they are trying to help.
It seems fair to believe that this amount of politicking and imposing culture is well above what could be considered unavoidable; abstinence-only hasn’t been shown to be effective anywhere, so it’s a waste of resources to push it on African countries.
This is an issue worthy of a lot more thought (at least for me); as Easterly puts it,
“The big question is whether poor Africans themselves would have chosen to spend scarce funds on prolonging so lives with AIDS treatment, as opposed to saving many lives with other health interventions.”
That’s a really tough question for someone generally optimistic about the effects of aid (done appropriately, anyway). With the funding for HIV/AIDS, it seems like a relatively straightforward answer: no, the poor recipients probably would not have spent those resources on HAART treatment. At the same time, there are myriad complexities that shouldn’t go unnoticed, too; for example, the fact that “studies in Cameroon, Guinea, Tanzania, and Uganda estimated that 30 to 70% of government drugs disappeared before reaching the patient” should give pause to the notion that the recipients themselves will always make the “best” decision.
The basic worry still stands, though; if the Western world is convinced that there is a place for Western aid, then it should grapple daily with the notion that the strictures it attaches to that aid are problematic, inefficient, and dilutive. Foreign aid is a scarce resource that is increasingly threatened by austerity measures in the United States, the United Kingdom, and elsewhere; making inefficient use of it both devalues the act itself (a dollar doesn’t go as far) and leads to poorer outcomes in areas where it is used.
PEPFAR and the World Health Organizations “3 by 5” campaign (to get three-million HIV-positive people on antiretrovirals by 2005) aren’t inherently bad – but they could be so much better. And – crucially – the path towards better is clear!
There are – and always will be – myriad examples where the path is much murkier. If the West doesn’t have the power to chart a path the obvious cases, how will we handle the less-obvious ones?