Tag Archive | health care

Does Development Work? Observations on Gates’ Annual Letter

Infant mortality is down worldwide

Infant mortality is down worldwide

Asking a question like “does development work” is like asking “does policy work”: it depends. I seem to be fielding questions about development with increasing frequency. Mostly I find that the harshest critics don’t know a whole lot about development and haven’t been to many places in the world, complicating my ability to respond in an reasoned manner. Development is a complicated beast but, the truth is, that it didn’t come easy for us 1%’ers either.

Every year, Bill and Melinda Gates release a letter on the state of the Gates Foundation and the current situation of global development and health. This time Gates set out to dispel three common myths on development, namely that poor countries are doomed to be poor forever, foreign aid is a total waste and that development will just lead to overpopulation.

The first is the most cynical, but even for us development/public health folks, it’s easy to be discouraged. Pessimism aside, the data don’t bear out the assumption that developing countries are entrenched in poverty. Just about all Sub-Saharan African countries experience consistent economic growth throughout the 00’s and have seen rapid improvements in just about all of the common health indicators. People are living longer, fewer kids are dying and they’re making more money to pay for school and health care.

Over the past five years that I’ve been going to Sub-Saharan Africa I’ve seen this change on the ground. Cars are in better shape, there’s more goods on the shelves, kids are better nourished and security has vastly improved. Does this mean that all of the problems are magically going away? No, there are still vast challenges to infrastructure development, access to health care and affordable medications, educational quality, gender issues and basic business development. However, these improvements do signal that Sub-Saharan African countries are reaching a point where sustained development is possible.

I have a hard time disagreeing with Gates here, but I did find his “before” and “after” pictures of Nairobi a bit bizarre. Though Nairobi is currently going through a construction boom, I fail to see how it would look any different in 2014 than it did in 1969 after more than three decades of stagnation.

Gates second point and the hardest myth to dispel is that of the alleged ineffectiveness of aid. Bill Easterly has made a career out of aid bashing, and, unfortunately, given cynical politicians looking for policy scapegoats a point to scream to their angry constituents. In a broader sense, the screaming over aid is really a questioning of developmental policies themselves. Certainly, there are development failures. The neo-classically informed structural adjustment policies of the World Bank and the IMF during the 80’s and 90’s were, on the surface, colossal failures (Read Beyond the World Bank Agenda: An Institutional Approach to Development by Howard Stein for a great analysis). On a smaller scale, we can easily cherry pick misguided but well meaning development projects or plans that simply went awry for any number of unforeseen reasons. The recent takedown of Jeff Sachs (The Idealist: Jeffrey Sachs and the Quest to End Poverty) and the massive problems of the Millenium Village in North East Province in Kenya is a great example of the challenges a development project can face.

However, in ever insular post Iraq America, the question that is most often asked is why we should even care and does our presence merely serve to make things worse. The truth is, and the point most often overlooked, is that most development projects are international collaborations. Many projects are conducted with partners in target countries and, more often than not, projects often make up for shortfalls that hobbled governments are unable (or sometimes unwilling) to provide. Health care is one example.

Jeff Sachs wrote a nice article this morning on how effective free insecticide treated nets have been in reducing malaria incidence and mortality in Sub-Saharan Africa. Nearly half a billion free nets have been given out worldwide as of 2014 and a lot of kids are alive today who would have been dead had they been born ten years earlier. Malaria is 100% associated with poverty. Wealthy people do not get malaria, even in malaria endemic countries. Though some of the decline in malaria incidence has been due to increased affluence and urbanization of African countries, a major percentage of this decline has been due to aid programs which provide bed nets and have expanded access to life-saving malaria medications. Certainly, not all aid works, but nothing works 100% of the time, particularly when humans are involved.

Which brings us to the most cynical and offensive of Gates’ three myths. Some people truly believe that saving African kids is a bad thing. One day there will be too many of them and they will suck up the ability for the world to sustain life. Honestly, this view couldn’t be more wrong.

The poorest parts of the world are the areas which are seeing the most rapid population growth. The average Malawian woman has 8 children in her lifetime, often starting when she isn’t even yet 15 years old. It has been said that if Malawi continues on it’s current trajectory, that it will have a population equivalent to that of Japan’s by 2050. Women in water and food constrained pastoralist communities can have ten or more children. The most affluent areas of Africa are the places with the slowest population growth.

Even more incorrect is the assumption that poverty is less harmful to the environment than development. Malawi is almost entirely deforested due to extensive use of charcoal for heating and tobacco cultivation. Deforestation not only robs the earth of potential carbon sinks, but also reduces need biodiversity and directly impacts precious water resources. Africa burns unclean fuels such as charcoal and coal for heating, and the poor condition of vehicles make it a major potential source of greenhouse gases. The air in Nairobi on any given weekday is so filled with exhaust that one can become dizzy just walking around town. It is, of course, unreasonable (and stupid) to deny Africans transportation and cooking fuel, but well meaning though poorly informed armchair environmentalists in the United States would happily suggest doing just that.

Which bring me to my final point. The case against development is one that assumes that the status quo is somehow preferable to anything that might come after. The assumption is that Africans were just fine without Europeans and their planet destroying ways. There is, of course, little data on what Africa was like before Europeans started extracting resources from the continent. We do, however, know a lot about underdeveloped areas of Africa. There is evidence to suggest that some do fine. There is however, much evidence to suggest that other simply do not. The worst parts of Africa are the parts which are the least developed. They are the areas where the market doesn’t function. The areas where there is little education, no access to health care, no roads, no economy, kids regularly die, where old people are a venerated since they are so rare, where there’s violence and instability and people are entirely marginalized from any level of political participation. While development likely will never solve the worst problems (like those in Somalia), there is no case to be made that the current state of the ultra poor is acceptable on any measure, even to the poor themselves!

Alright, off to bed.


Americans Die Earlier and Live Sicker than Everyone Else: Why?

DeathsI was just reading a recent op-ed in the Journal of the American Medical Association, “The US Health Disadvantage Relative to Other High-Income Countries
Findings From a National Research Council/Institute of Medicine (NRC/IOM) Report.”

Well, at least it’s an op-ed on a paper from the afformentioned NRC/IOM. The paper digs through data from 17 OECD countries and tracks trends in disease and mortality.

Americans fare worse than other OECD countries in:

• infant mortality and low birth weight
• injuries and homicides
• adolescent pregnancy and sexually transmitted infections
• HIV and AIDS
• drug-related deaths
• obesity and diabetes
• heart disease
• chronic lung disease
• disability

We also tend to die earlier than everyone else (75.64 years) but really can expect to live about as long as Finns (75.86), Portuguese (75.87) and Danes (76.13).

I’m not surprised that we ended up on the bottom of the list. We certainly have much to be ashamed of in terms of social violence, access to means to kill one another when enraged, and a fractured and inefficient health care system (or lack thereof).

What struck me is how varied the list is. Some elements (accidents, homicides and drug-related deaths) have nothing to do with access and quality of health care. Infant mortality and birth weight shouldn’t be so low in a well fed country like the United States.

The JAMA article sums a lot of the systematic problems of US health care and its potential impact on human welfare:

What could explain a health disadvantage that involves conditions as varied as motor vehicle crashes, heart disease, preterm birth, and diabetes? The NRC/IOM panel explored this paradox and found clues in almost every class of health determinants it considered. The United States lacks universal health insurance coverage, and its health system has a weaker foundation in primary care and greater barriers to access and affordable care.4 Care coordination also is a problem. In multiple surveys of patients with chronic illnesses in up to 11 countries, The Commonwealth Fund has shown that US patients are more likely than patients elsewhere to report lapses in care quality and safety outside of hospitals.1 US patients appear more likely than those in other countries to require emergency department visits or readmissions after hospital discharge, perhaps because of premature discharge or problems with ambulatory care. Confusion, poor coordination, and miscommunication between clinicians and patients are reported more often in the United States than in comparable countries.

But we know all this. Continuing:

Health is determined by more than health care, and the NRC/IOM panel explored differences beyond health care to explain the US health disadvantage. It considered individual behaviors and found that although US adults are less likely to smoke (due to successful tobacco control efforts) and may drink less alcohol than adults in peer countries, they have a greater propensity for other unhealthy behaviors. People in the United States consume more calories per capita, are more likely to abuse drugs, are less likely to fasten seat belts, have more motor vehicle crashes involving alcohol, and own more firearms than do people in other high-income countries. US adolescents seem less likely to practice safe sex than adolescents in European countries. These problems are not products of the health care system

But what I’m seeing here is a pattern. All of these problems are concentrated in the poorest strata of the American population. Drug abuse, violence, poor diets, lack of access to health care.. these are all problems non-existent in all but the most troubled areas of the country.

This is, of course, an unforgivable condition. However, given the plurality of the United States, evaluating Americans as a group masks the true problems. Life expectancies are presented as averages. That is, all deaths are recorded, even those in the top 50% of American households, those with health insurance, those who go to the gym, those who eat relatively well, those who won’t kill one another during a family fight, those who won’t use coke, crack, heroin, meth or even abuse oxycontins. All of these households bring the average up.

If we were to only look at the bottom 50%, a much more homogeneous group than that of all Americans, we would find that the average life expectancy to be frighteningly low. We would find that the incidence of avoidable disease is extremely high, the chances of getting shot high, access to health care minimal and a general state of un-health among them all. We already know that African Americans die about four years earlier than white Americans. In total, though, we’d probably find socioeconomic worlds within the United States as different as that of countries like Somalia and Germany.

Note: Ezra Klein also wrote something on this report.

Elysium: South Africa Light

Elysium-imax-poster-matt-damonLast night, I watched Neil Blomkamp’s science fiction opus Elysium, which was about as underwhelming as his previous work, “District 9.”

Though most American viewers will miss it, it’s impossible to watch Elysium without thinking of South Africa. Elysium is the name of a giant gated community in the sky that we mostly don’t get to see. The residents of Elysium live in huge mansions, complete with swimming pools and trimmed lawns. Most salient to the story is their access to medical care which allows them to live forever.

Elysium is propped up by a single corporation, which manufactures robots for use on Elysium as servants, and as security on Earth below. Our hero Max is a shanty town dweller and former criminal who works on an assembly ling of one of the factories. He gets hit with a lethal dose of radioactivity, and must get to Elysium to get medical care or die in five days.

Fine. What’s striking is all of the references to South Africa’s apartheid government, which propped up state protected private monopolies to keep and consolidate power for the white minority, while insuring a steady flow of cheap and disposable labor.

Max’s nemesis is the hulking Kruger, the only obvious South African of the film. We see him enjoying African BBQ and drinking Castle Lager, an obvious allusion to the South African 32 Battalion, sent to fight the communists in Angola and along the Namibian border during the 70’s and 80’s. In fact, his spaceship (?) has a (current) South African flag emblazoned on it.

The most despicable character of the film is dressed up to emulate IMF chairman Christine LaGarde. Oddly, Ms. LaGarde has deviated from her more mundane duties of monetary policy and gone militaristic, happily shooting down ships filled with crippled children looking for medical care.

In the end, the computer controlled hegemony of Elysium is toppled, though, not through the collective uprising and political struggle of the poor majority, but through the nameless efforts of a smuggler. Blomkamp, for all his detailed references to South Africa’s history, delivers it a cheap shot by excluding this important detail.

Of interest, though, is the final move from a designed state protected private economy, to a presumably socialist economy, where health care is available for all. While I like the move to freely available and quality health care for all, it’s odd that the film doesn’t do much to address how the economy is to move forward.

But the economic questions are the most perplexing of the movie, but then the economy of the South African apartheid government and even the present government are perhaps equally bizarre. Why would even the most wealthy concentrate all their wealth into a single, non-competitive space? We can assume that the wealthy in Elysium are obtaining socialist kick backs from their oppressive form of government, but it doesn’t make a whole lot of sense that someone on Elysium wouldn’t go it alone and seek other opportunities. In this sense, the people are Elysium are at least as oppressed as those on Earth. You’d wonder how they’d put up with it. Wouldn’t someone get bored?

Also, with so many humans on Earth, you’d assume that someone might think of this as a major opportunity for investment. It’s pretty clear that the people on Elysium don’t have to use cash, but on Earth, the potential for grass roots markets seems limitless. One of the main characters of the film has tapped into the market of smuggling people up to Elysium for medical care. The entrepreneurial spirit is alive on Earth. Wouldn’t someone on Elysium try to tap into this, reacting to market demand and helping people at the same time? This was certainly the story in expanding access to HIV antiretrovirals in Africa (in a really, really simple sense, don’t flame me, man!). There’s no reason to assume the same wouldn’t play out here.

But that’s asking too much, and I digress.

Elysium’s two dimensionality is really what hobbles the film. Like District 9, what could have been a really clever allegory for unequal societies and the structural problems which produce and support them, Elysium fades off into a bland world of polarized, Hollywood science fiction. It fails to explore how humans push back against inequality and fails to educate its audience as to what it all means. Blomkamp clearly understands the issues. Hopefully, he’ll deliver the goods next time.

Tea Party Insanity: We All Lose

The United States of America has the worst health care system in the developed world. Though we develop some of the most advanced medical technologies, pharmaceuticals, procedures and research and despite the fact that we can claim some of the finest physicians in the world, our health system is expensive and mostly unavailable to the people most likely to become ill.

As a country, we have the worst health profile in the developed world falling behind all of our peers including Sweden, Germany, Japan, Italy, Turkey and even our totalitarian brothers in the north, Canada. We can even claim the embarrassing distinction of having an infant mortality rate higher than that of impoverished Cuba, despite being the wealthiest country that human history has ever seen.

It’s an absolute embarrassment. The inexplicable inability of a country as wealthy and powerful as the US to guarantee even basic protections of health to its citizens makes me incredibly ashamed to be an American.

Clearly, as Mr. Obama put it, a fraction of a single political party in a single house in a single branch of government doesn’t agree with me. In fact, their crass shutdown of the Federal Government in the name of nothing more than ideological insanity is an affront not only to Americans, but all of humanity. If we are a country that now values politics and control as more important than human health and life, then we have truly lost our way.

The irony is that the Affordable Care Act is only a modest improvement to a truly inhumane and awful health care system. It does not provide us with a Cuban or even a Canadian style system. It does not fully eliminate the possibility of household devastation given a calamitous health event. It does not erase the specter of medical debt that many low and middle class households face every day.

It sadly shies away from implementing rigid price controls as those in mighty Japan; prices controls which keep health care affordable, while still preserving a competitive and profitable health care technologies market.

It does not fully release us from a state of health care bondage that keeps Americans from starting new businesses or changing jobs; unlike powerful and economically vibrant Sweden, where even the most risky of start-ups are possible, due to a basic guarantee of health care.

It only barely offers a guarantee to the poor, who, while ensuring ample profits for the Wal Marts and the McDonalds by working for pennies, face the severest of health problems. The disproportionately poor health profiles of the poor are not free. By not providing sufficient care and wages, the Wal Marts and McDonalds of the world shift those expenses onto taxpayers, so that we effectively subsidize their enterprises. Worse yet, since we refuse to acknowledge it, we manage it inefficiently, raising costs for everyone.

Failure to provide health care to poor people (or anyone else) in an efficient and transparent manner wreaks havoc on our economy, robs governments of dollars that could be better assigned to upgrading our aging infrastructure and degrades the ability of our workforce to be productive. Yet, Republicans oppose it.

I can’t think of any rational reason outside that they might have secretly started smoking weed in their own quarters.

The Affordable Care Act falls far short of my vision of a truly inclusive and effective health care insurance scheme for America. Despite this, it is a milestone improvement to an embarrassingly poor “system.”

The government shutdown to protest the Affordable Care Act has simply left me more emotionally numb than even the attacks in Kenya. Sometimes, I try to convince myself that, under all the insane rhetoric, the American right wing is a rational beast and that they have legitimate concerns and offer reasonable solutions. If this ideological shutdown over providing negligible improvements to a failing system of health care in America is any indication, insanity has truly prevailed.

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