Brookings: Topics - Global Health

Own the Goals: What the Millennium Development Goals Have Accomplished

John McArthur — Thu, 21 Feb 2013 14:11:00 -0500

For more than a decade, the Millennium Development Goals -- a set of time-bound targets agreed on by heads of state in 2000 -- have unified, galvanized, and expanded efforts to help the world's poorest people. The overarching vision of cutting the amount of extreme poverty worldwide in half by 2015, anchored in a series of specific goals, has drawn attention and resources to otherwise forgotten issues. The MDGs have mobilized government and business leaders to donate tens of billions of dollars to life-saving tools, such as antiretroviral drugs and modern mosquito nets. The goals have promoted cooperation among public, private, and nongovernmental organizations (NGOs), providing a common language and bringing together disparate actors. In his 2008 address to the UN General Assembly, the philanthropist Bill Gates called the goals "the best idea for focusing the world on fighting global poverty that I have ever seen."

The goals will expire on December 31, 2015, and the debate over what should come next is now in full swing. This year, a high-level UN panel, co-chaired by British Prime Minister David Cameron, Liberian President Ellen Johnson Sirleaf, and Indonesian President Susilo Bambang Yudhoyono, will put forward its recommendations for a new agenda. The United States and other members of the UN General Assembly will then consider these recommendations, with growing powers, such as Brazil, China, India, and Nigeria, undoubtedly playing a major role in forging any new agreement. But prior to deciding on a new framework, the world community must evaluate exactly what the MDG effort has achieved so far.

WORKING ON A DREAM

The MDGs are not a monolithic policy following a single trajectory. Ultimately, they are nothing more than goals, established by world leaders and subsequently reaffirmed on multiple occasions. The MDGs were not born with a plan, a budget, or a specific mapping out of responsibilities. Many think of the MDGs as the UN's goals, since the agreements were established at UN summits and UN officials have generally led the follow-up efforts for coordination and reporting. But the reality is much more complicated. No single individual or organization is responsible for achieving the MDGs. Instead, countless public, private, and nonprofit actors-working together and independently, in developed and developing countries -- have furthered the goals. Amid this complexity, the achievements toward reaching the MDGs are all the more impressive. The goals have brought the diffuse international development community closer together.

Before the MDGs were crafted, there was no common framework for promoting global development. After the Cold War ended, many rich countries cut their foreign aid budgets and turned their focus inward, on domestic priorities. In the United States, for example, the foreign aid budget hit an all-time low in 1997, at 0.09 percent of gross national income. Meanwhile, throughout the 1990s, institutions such as the World Bank and the International Monetary Fund (IMF) encouraged developed and developing countries to scale back spending on public programs-in the name of government efficiency-as a condition for receiving support.

The results were troubling. Africa suffered a generation of stagnation, with rising poverty and child deaths and drops in life expectancy. Economic crises and the threat of growing inequality plagued Asia and Latin America. The antiglobalization movement gained such force that in November and December 1999, at what has come to be called "the Battle in Seattle," street protesters forced the World Trade Organization to cancel major meetings midstream.

The suspicions on the part of civil society carried over into policy debates. In the late 1990s, the Organization for Economic Cooperation and Development proposed "international development goal" benchmarks for donor efforts. The OECD's proposal was later co-signed by leaders of the IMF, the World Bank, and the UN. In response, Konrad Raiser, then head of the World Council of Churches, hardly a fire-breathing radical, wrote UN Secretary-General Kofi Annan to convey astonishment and disappointment that Annan had endorsed a "propaganda exercise for international finance institutions whose policies are widely held to be at the root of many of the most grave social problems facing the poor all over the world."

That proposal never got off the ground, but the international community made other progress in the lead-up to 2000 that helped set the groundwork for the MDGs. Most notably, G-8 leaders took a major step forward when they crafted a debt-cancellation policy at their 1999 summit in Cologne, Germany. Under this new policy, countries could receive debt relief on the condition that they allocated savings to education or health. This helped reorient governments toward spending in social sectors after many years of cutbacks.

At the 2000 UN Millennium Summit, which was the largest gathering of world leaders to date, heads of state accepted that they needed to work together to assist the world's poorest people. Looking at the challenges of the new century, all the UN member states agreed on a set of measurable, time-bound targets in the Millennium Declaration. In 2001, these targets were organized into eight MDGs: eradicate extreme poverty and hunger; achieve universal primary education; promote gender equality and empower women; reduce child mortality; improve maternal health; combat HIV/AIDS, malaria, and other diseases; ensure environmental sustainability; and forge global partnerships among different countries and actors to achieve development goals. Each goal was further broken down into more specific targets. For example, the first goal involves cutting in half "between 1990 and 2015, the proportion of people whose income is less than $1 a day."

In practical terms, the MDGs were actually launched in March 2002, at the UN International Conference on Financing for Development, in Monterrey, Mexico. The attendees, including heads of state, finance ministers, and foreign ministers, agreed that developed countries should step in with support mechanisms and adequate financial aid to help poor countries committed to good governance meet the MDG targets. Crucially, leaders set a benchmark for burden sharing when they urged "developed countries that have not done so to make concrete efforts towards the target of 0.7 percent of gross national income (GNI) as official development assistance to developing countries." At the time of the conference, the 22 official OECD donor countries allocated an average of 0.22 percent of GNI to aid. Thus, working toward a 0.7 target implied more than tripling total global support. The Monterrey conference established the MDGs as the first global framework anchored in an explicit, mutually agreed-on partnership between developed and developing countries.

THE GLOBAL CONVERSATION

These historic intergovernmental agreements have inspired much debate. Some NGO leaders, including participants in the annual World Social Forum, distrusted any agreement that involved international financial institutions and was negotiated behind closed doors. Human rights activists were dismayed that the MDGs excluded targets for good governance, which they considered a contributor to development and a key outcome unto itself. Some environmental activists were bothered by the narrow formulation of the targets, which ignored major issues, such as climate change, land degradation, ocean management, and air pollution.

To be sure, the MDG framework is imperfect. Several issues, such as gender equality and environmental sustainability, are defined too narrowly. The education goal is limited to the completion of primary school, overlooking concerns about the quality of learning and secondary school enrollment levels. In addition, some academics, such as the economist William Easterly, argue that the remarkable ambition of the goals is unfair to the poorest countries, which have the furthest to go to meet the targets, and minimizes what progress those countries do achieve. Sure enough, if the child survival goal were to cut mortality by half, instead of by two-thirds, 72 developing countries would already have met the target by 2011. Instead, the two-thirds goal has been achieved by only 20 developing countries so far. In addition, the MDGs' emphasis on human development issues, such as education and health, sometimes downplays the importance of investments in energy and infrastructure that support economic growth and job creation.

Nonetheless, the framework has provided a global rallying point. In 2002, with a mandate from Annan and Mark Malloch Brown, then the administrator of the UN Development Program, the economist Jeffrey Sachs launched the UN Millennium Project, which brought together hundreds of experts from around the world from academia, business, government, and civil-society organizations to construct policy plans for achieving the goals. Sachs also tirelessly lobbied government leaders in both developed and developing countries to expand key programs, especially in health and agriculture, in order to meet the MDG targets.

In the lead-up to the 2005 G-8 summit, in Gleneagles, Scotland, advocacy organizations worldwide championed the MDGs. In developing countries, NGO leaders, such as Amina Mohammed, Kumi Naidoo, and Salil Shetty, encouraged civil-society leaders to hold their governments accountable for meeting the goals. In developed countries, organizations such as ONE, co-founded by the activist Jamie Drummond, the rock star Bono, and others, petitioned politicians and conducted public awareness campaigns to demand that world leaders step up their efforts to meet the targets. At the summit, British Prime Minister Tony Blair and Gordon Brown, then British chancellor of the exchequer, put the MDGs and foreign aid commitments at the top of the agenda. Leaders at Gleneagles committed to increasing global aid by $50 billion by 2010 and set the groundwork for larger commitments to be made by 2015. However, one powerful player on the world stage, the United States, remained hesitant to embrace the MDG agenda.

PLAYERS ON THE BENCH

U.S. President George W. Bush launched the Millennium Challenge initiative in 2002, promising a 50 percent increase in U.S. foreign aid within three years, with money going to countries committed to good governance. The initiative drew inspiration from the MDGs, as the name suggests, but confusingly, it did not directly link to the targets. Ten months later, in his 2003 State of the Union address, Bush launched the President's Emergency Plan for AIDS Relief, which has dramatically improved access to AIDS treatment in the developing world. This program was in many ways in line with the MDG effort but did not explicitly link to the goals. Bush even endorsed the UN Millennium Declaration and the Monterrey agreements, but he refused to support the MDGs, largely because his administration viewed them as UN-dictated aid quotas.

Holding a similar view, State Department officials regularly claimed that they supported the targets of the Millennium Declaration but not the MDGs, despite the fact that the MDG targets were drawn directly from the Millennium Declaration. U.S.-UN tensions over the Iraq war were a critical backdrop, with the Bush administration reticent to support a major UN initiative. Washington's aversion was so strong that many U.S. advocacy groups avoided using the term "Millennium Development Goals" for fear of losing influence. When John Bolton became the U.S. ambassador to the UN in August 2005, one of his first actions was to suggest deleting all references to the MDGs in the drafted agreement of the upcoming UN World Summit. The subsequent uproar from other countries and U.S. media outlets forced Washington to modify its position. In his summit speech, Bush finally endorsed the MDGs, using the phrase "Millennium Development Goals" publicly for the first time.

By refusing to directly engage with the MDGs in their early years, the United States missed an opportunity to highlight its contributions to development efforts and foster international goodwill. In the early years of this century, the United States helped revolutionize global health, a central pillar of the MDGs, first through Bush's AIDS initiative and later through efforts on malaria and other deadly diseases. Furthermore, by resisting a project on which most of the world was actively collaborating, Washington missed easy opportunities to build political capital for solving much thornier and divisive international issues.

Diplomatic tensions have subsided under the Obama administration, which has given much stronger rhetorical support to the MDGs and has continued the previous administration's basic development policies, in addition to launching a major initiative to reduce poverty by supporting small farms around the world. Nevertheless, many officials in Washington remain either skeptical or disengaged when it comes to the MDGs, most likely because of a long-standing aversion to fixed foreign aid spending, especially when defined by an international agreement. This fear, however, is baseless. The MDGs do not dictate any aid commitments, and the only related figure, the 0.7 aid target, which countries agreed to work toward in Monterrey in 2002, was endorsed by Bush. It was only later that some countries, such as the United Kingdom, made timetables to meet this aid target.

The World Bank has similarly missed out. Although the bank has championed the framework at senior political levels, it has not adequately facilitated MDG efforts on the ground. Early resistance was in part due to bureaucratic resentment of the UN for its having been given such a prominent role on development issues. In addition, as an institution dominated by economists, the bank is prone to prioritize economic reforms over investment in social sectors. Even more, there is widespread distrust among the bank's staff that donor countries will provide adequate financing for the MDGs. Such concerns are not without merit, as the G-8 ended up falling more than $10 billion short on its Africa pledges for 2010 alone.

Nevertheless, the bank, as a main interlocutor with the developing world, should have helped poor countries assess how they could achieve the MDGs and sounded the alarm about donor financing gaps. Furthermore, the bank has a self-serving reason to get onboard: the MDGs spurred a major budgetary expansion for the International Development Association, the branch of the bank devoted to supporting the poorest countries. Fortunately, the United States and the World Bank are coming around on the MDGs, attracted by the proven success of the framework.

IT'S A SMALL WORLD AFTER ALL

As of late 2010, five years before the deadline, the world had already met the overarching MDG of cutting extreme poverty by half. The estimated share of the developing-world population living on less than $1.25 per day (the technical MDG measurement of extreme poverty) had dropped from 43 percent in 1990 to roughly 21 percent in 2010. This statistic is somewhat skewed by progress that was under way in China and other Asian countries long before the MDGs were adopted. The framework is not solely responsible for all of the advancements of the past 12 years. Many other forces, such as the expansion of global markets and the creation of groundbreaking health and communications technologies, have helped the developing world. Moreover, the goals relating to hunger, sanitation, and the environment have not been met. Poverty reduction, however, has progressed in every region since 2000. Even excluding China from the global calculation, the world's share of impoverished people fell from 37 percent in 1990 to 25 percent in 2008, and forthcoming data should show an even greater drop.

Most important, the MDGs have kick-started progress where it was lacking, especially in Africa, where unprecedented economic growth and poverty reduction are now taking place. From 1981 to 1999, extreme poverty in sub-Saharan Africa rose from 52 percent of the population to 58 percent. But since the launch of the MDGs, it has declined sharply, to 48 percent in 2008. Much of this was likely driven by MDG-backed investments in healthier and better-educated work forces in the region. The global MDG campaign has also prompted support for small subsistence and cash-crop farms, which has boosted growth in many low-income countries, such as Malawi.

Primary education rates have increased around the world, too, with South Asia and sub-Saharan Africa experiencing particularly big jumps in enrollment. Much of this has been the result of funding from MDG-linked initiatives, such as the Global Partnership for Education, launched in 2002 by the World Bank and other development organizations to help poor countries "address the large gaps they face in meeting education MDG 2 and 3, in areas of policy, capacity, data, finance." These same efforts have helped nearly every world region achieve gender parity in classrooms.

The greatest MDG successes undoubtedly concern health. The MDGs have invigorated multilateral institutions, such as the GAVI Alliance (formerly called the Global Alliance for Vaccines and Immunization), which seeks to achieve MDGs "by focusing on performance, outcomes and results." The goals have also inspired a huge increase in private-sector aid. Ray Chambers, a respected philanthropist and co-founder of a New York private equity firm, first learned of the goals in 2005. Since then, working with Sachs and others, Chambers has coordinated a worldwide coalition of policy, business, and NGO leaders in an effort to help the developing world meet the goal for malarial treatment and prevention. Thanks in part to this global effort, malaria-related mortality has dropped by approximately 25 percent since 2000, with most of those gains probably occurring since 2005. Many pharmaceutical companies have also put forth major efforts to make their medicines more widely available in poor countries, and new initiatives are continuing to take shape. The MDG Health Alliance, founded in 2011, is comprised of business and NGO leaders around the world working toward the MDG health targets, including the elimination of mother-to-child HIV transmission.

The combined results of these campaigns are remarkable. For example, in Senegal, child mortality has plummeted by half since 2000. In Cambodia, it has dropped by 60 percent. Rwanda has recorded a ten percent average annual reduction since 2000, one of the fastest declines in history. Even China has seen a significant decrease in child deaths, possibly because the expanded global emphasis on health has encouraged the country's policymakers to pay more attention to relevant issues. Overall, despite rapid global population growth, there has been a decrease in children dying worldwide before their fifth birthdays, from 11.7 million in 1990 to 9.4 million in 2000 and 6.8 million in 2011.

No issue has been more closely interconnected with the MDGs than the HIV/AIDS treatment campaign. In 2000, nearly 30 million people were infected, the vast majority in Africa, where only approximately 10,000 people were in treatment and over one million people were dying every year from the disease. The next year, the head of the U.S. Agency for International Development publicly deemed large-scale AIDS treatment in Africa impossible. Undeterred, Annan launched the Global Fund to Fight AIDS, Tuberculosis and Malaria, which aims to achieve "long-term outcome and impact results related to the Millennium Development Goals."

Spurred by the launch of the MDGs, Jim Yong Kim, then head of the World Health Organization's HIV/AIDS department, introduced the "3 by 5" initiative in 2003, which aimed to have three million people living with AIDS in the developing world receiving treatment by 2005. By the end of 2005, only 1.3 million people were receiving treatment-fewer than half of the target. But thanks to the interwoven AIDS-MDG campaign, the notion of service delivery targets has sunk in globally, helping expand AIDS treatment by orders of magnitude: also in 2005, the G-8 and the UN General Assembly endorsed a target of universal access to treatment by 2010, backed by major financial commitments. The MDG movement has expanded the world's ambitions in tackling health crises and made extraordinary progress. In 2011, more than eight million people worldwide were receiving AIDS treatment.

NEXT-GENERATION GOALS

The MDGs have proved that with concentration and effort, even the most persistent global problems can be tackled. The post-2015 goals should remain focused on eliminating the multiple dimensions of extreme poverty, but they also need to address emerging global realities. These new challenges include the worsening environmental pressures affecting the livelihoods of hundreds of millions of people, the growing number of middle-income countries with tremendous internal poverty challenges, and rapidly spreading noncommunicable diseases.

The new goals also need to be matched with resources. Without the Monterrey agreements of 2002 and the financial commitments made at the Gleneagles summit in 2005, the MDGs might well have faded from the international agenda. It is crucial that the post-2015 negotiations not be left solely to foreign and development ministries. Finance ministries will need an equal say on many of the most central issues and therefore need to be included from the beginning. Other relevant ministries, such as those that deal with health and environmental issues, should be consulted regularly. Additionally, in preparation for 2015, multilateral organizations, such as the World Bank and UN agencies, should conduct independent external reviews of their contributions to the MDGs and identify benchmarks for post-2015 success based on the results. And the United States needs to join the international community in making a solid commitment to long-term, goal-oriented foreign aid.

The MDGs have helped mobilize and guide development efforts by emphasizing outcomes. They have encouraged world leaders to tackle multiple dimensions of poverty at the same time and have provided a standard that advocates on the ground can hold their governments to. Even in countries where politicians might not directly credit the MDGs, the global effort has informed local perspectives and priorities. The goals have improved the lives of hundreds of millions of people. They have shown how much can be achieved when ambitious and specific targets are matched with rigorous thinking, serious resources, and a collaborative global spirit.

Looking forward, the next generation of goals should maintain the accessible simplicity that has allowed the MDGs to succeed and also facilitate the creation of better accountability mechanisms both within and across governments. In addition, the new goals need to give low- and middle-income countries a greater voice in shaping the agenda. Most important, momentum matters. Just as progress in individual MDG areas has inspired other campaigns, so work done now, in the final stretch, will affect what happens in the future. The results achieved by 2015 will mark an endpoint, but even more, they will provide a springboard for the next generation of goals. There is no time to lose.

Authors

John McArthur

Publication: Foreign Affairs

Image Source: © Mohamed Nureldin Abdallah / Reuters

The United States and Global Development: An Approach in Transition

Tue, 19 Feb 2013 14:00:00 -0500

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February 19, 2013
2:00 PM - 3:30 PM EST

Saul/Zilkha Rooms
Brookings Institution
1775 Massachusetts Avenue NW
Washington, DC 20036

As President Barack Obama begins his second term, the U.S. global development community is taking stock of the reform efforts that began in 2010 to elevate development—joining defense and diplomacy—as a core pillar of U.S. national security and foreign policy, while advancing proposals for what the administration should focus on going forward. In January 2013, the Modernizing Foreign Assistance Network (MFAN), a reform-minded coalition that is focused on advancing the effectiveness and impact of U.S. global development efforts, submitted its recommendations to President Obama.

On February 19, the Development Assistance and Governance Initiative at Brookings and MFAN co-hosted a discussion on the current status and future of the U.S. global development reform agenda. Panelists included: Sheila Herrling, vice president, department of policy and evaluation at the Millennium Challenge Corporation; Steven Radelet, distinguished professor in the practice of development at Georgetown University; Susan Reichle, assistant to the administrator at the Bureau of Policy, Planning and Learning at the U.S. Agency for International Development; and Connie Veillette, former director of the Rethinking U.S. Foreign Assistance Program at the Center for Global Development. Brookings Senior Fellow George Ingram moderated the discussion.

Impacts of Malaria Interventions and their Potential Additional Humanitarian Benefits in Sub-Saharan Africa

David L. Caprara and Ken Ballen — Fri, 26 Oct 2012 14:24:00 -0400

INTRODUCTION

Over the past decade, the focused attention of African nations, the United States, U.N. agencies and other multilateral partners has brought significant progress toward achievement of the Millennium Development Goals (MDGs) in health and malaria control and elimination. The potential contribution of these strategies to long-term peace-building objectives and overall regional prosperity is of paramount significance in sub-regions such as the Horn of Africa and Western Africa that are facing the challenges of malaria and other health crises compounded by identity-based conflicts.

National campaigns to address health Millennium Development Goals through cross-ethnic campaigns tackling basic hygiene and malaria have proven effective in reducing child infant mortality while also contributing to comprehensive efforts to overcome health disparities and achieve higher levels of societal well-being.

There is also growing if nascent research to suggest that health and other humanitarian interventions can result in additional benefits to both recipients and donors alike.

The social, economic and political fault lines of conflicts, according to a new study, are most pronounced in Africa within nations (as opposed to international conflicts). Addressing issues of disparate resource allocations in areas such as health could be a primary factor in mitigating such intra-national conflicts. However, to date there has been insufficient research on and policy attention to the potential for wedding proven life-saving health solutions such as malaria intervention to conflict mitigation or other non-health benefits.

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David L. Caprara
Ken Ballen

Image Source: © Handout . / Reuters

AIDS 2012: Key Lessons from a Decade of Action on Global AIDS, and the Way Forward

Mon, 25 Jun 2012 10:00:00 -0400

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June 25, 2012
10:00 AM - 11:00 AM EDT

Falk Auditorium
Brookings Institution
1775 Massachusetts Avenue, N.W.
Washington, DC 20036

On June 25, Brookings hosted Ambassador Eric Goosby, M.D., United States Global AIDS Coordinator, for a discussion of key themes at the XIX International AIDS Conference, which took place July 22-27, 2012 in Washington, DC.

Ambassador Goosby discussed lessons from the first decade of the President’s Emergency Plan for AIDS Relief (PEPFAR), focusing on successes that can inform future efforts on AIDS and global health. In his role as U.S. Global AIDS Coordinator, Ambassador Goosby oversees implementation of PEPFAR, as well as U.S. government engagement with the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Ambassador Goosby has more than 25 years of experience with HIV/AIDS, ranging from his early years treating patients at San Francisco General Hospital when AIDS first emerged, to engagement at the highest level of policy leadership. From 2001 to 2009, he served as CEO and Chief Medical Officer of Pangaea Global AIDS Foundation. He also previously served as professor of Clinical Medicine at the University of California, San Francisco. During the Clinton Administration, he served as Deputy Director of the White House National AIDS Policy Office and Director of the Office of HIV/AIDS Policy of the U.S. Department of Health and Human Services. As the first director of the Ryan White Care Act at the U.S. Department of Health and Human Services, Ambassador Goosby helped develop HIV/AIDS delivery systems in the United States.

Brookings Fellow Noam Unger provided introductory remarks and moderated the discussion. After the program, Ambassador Goosby took audience questions.

You can follow the conversation on this event on Twitter using the hashtag #AIDS2012.

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AIDS 2012: Key Lessons from a Decade of Action on Global AIDS, and the Way Forward

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The Inequitable Impact of Health Shocks on the Uninsured in Namibia

Emily Gustafsson-Wright, Jacques van der Gaag and Wendy Janssens — Mon, 19 Mar 2012 00:00:00 -0400

ABSTRACT

The AIDS pandemic in sub-Saharan Africa puts increasing pressure on the buffer capacity of low- and middle-income households without access to health insurance. This paper examines the relationship between health shocks, insurance status and health-seeking behaviour. It also investigates the possible mitigating effects of insurance on income loss and out-of-pocket health expenditure. The study uses a unique dataset based on a random sample of 1769 households and 7343 individuals living in the Greater Windhoek area in Namibia. The survey includes medical testing for HIV infection which allows for the explicit analysis of HIV-related health shocks. We find that the economic consequences of health shocks can be severe for uninsured households even in a country with a relatively well-developed public health care system such as Namibia. The uninsured resort to a variety of coping strategies to deal with the high medical expenses and reductions in income, such as selling assets, taking up credit or receiving financial support from relatives and friends. As HIV-infected individuals increasingly develop AIDS, this will put substantial pressure on the public health care system as well as social support networks. Evidence suggests that private insurance, currently unaffordable to the poor, protects households from the most severe consequences of health shocks.

Read the full article on Oxford Journals »

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Publication: Oxford Journals

Image Source: © Kevin Lamarque / Reuters

@ Brookings Podcast: Can the World Sustain Seven Billion People?

Homi Kharas — Fri, 06 Jan 2012 16:20:00 -0500

With better health care and nutrition, people around the world are living longer and having more children, pushing the population of planet Earth above the seven billion mark. Expert Homi Kharas says while the reasons for growth are positive, the population explosion means world governments must develop more sustainable policies to provide goods and services.

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Which Health Conditions Cause The Most Unhappiness?

Carol Graham, Lucas Higuera and Eduardo Lora — Tue, 14 Dec 2010 14:32:00 -0500

Editor’s note: The full version of this paper is published in Health Economics (subscription required).

Abstract —

This paper assesses the effects of different health conditions on happiness. Based on new data for Latin America, we examine the effects of different conditions across age, gender, and income cohorts. Anxiety and pain have stronger effects than physical problems, likely because people adapt better to one-time shocks than to constant uncertainty. The negative effects of health conditions are very large when compared with the effects of income on happiness. And, while higher peer income typically elicits envy, better peer health provides positive signals for life and health satisfaction. Health norms vary widely across countries.

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Authors

Carol Graham
Lucas Higuera
Eduardo Lora

Publication: Health Economics

Nigeria's HIV/AIDS Pandemic: Time for Bolder Action

Richard Joseph — Fri, 11 Jun 2010 15:50:00 -0400

Among the long list of Nigeria’s woes, AIDS is seldom mentioned. Yet, Nigeria has the second largest number of HIV-infected persons in the world, now estimated at 3 million. If South Africa, the country with the largest number of HIV-infected persons, succeeds in sharply reducing its infection rate, will Nigeria eventually surpass it on the world HIV/AIDS chart? That is statistically possible given Nigeria’s population, three times larger at 150 million, and its weaker health and other infrastructures.

What will it take to curb Nigeria’s spiraling AIDS pandemic? A team of Nigerian and American researchers, supported by the University of Ibadan, Nigeria and Northwestern University have sought answers by studying the social, economic and political barriers to effective prevention and treatment. The program is the Research Alliance to Combat HIV/AIDS (REACH) whose data and findings were presented in Nigeria’s capital, Abuja, on May 4. Other dissemination events followed at the two collaborating institutions, at the Chicago Council on Global Affairs, and concluded at the Brookings Institution on May 27.

For several years, the central focus of the AIDS campaign has been the provision of anti-retroviral drugs and creating the necessary testing and monitoring facilities. It has brought life-saving treatment to 4 million people worldwide. But that has left 6 million with the disease currently untreated. In sub-Saharan Africa, five persons are newly infected for every two receiving medical care. The number of infected persons is growing faster than the pool of donor funds to treat them. U.S. aid dollars now cover the cost in Nigeria of counseling and treatment for 300,000 of the 350,000 under care. Yet 200,000 are untreated under the current guidelines. Over a million more would be treated if Nigeria sought to comply with new World Health Organization guidelines for starting drug treatment. Not only must Nigeria find a way to get treatment to the large pool of infected persons, it has to slow its rate of infection. These two interrelated challenges can only be surmounted by an exceptionally bold, comprehensive and sustained effort.

REACH began on the premise, now all-too-evident, that treatment was just one part of the answer. Today, not only are many infected persons not treated, a substantial number do not know their HIV status and thus continue transmitting the disease. Even proven prevention techniques are blunted in Nigeria because of the country’s woeful public health system. Only 62 percent of pregnant women in REACH studies have had HIV counseling and testing (HCT). Of those tested, almost a third did not return for their results. Yet, the timely administering of long available drugs can sharply reduce transmission of the virus to newborns. It is not surprising that 56,000 HIV-infected babies are born each year in Nigeria.

On the basis of REACH survey data, Nigeria, via its National Agency for the Control of AIDS (NACA), can begin a substantially scaled-up program. A key component of this program would be expanded community studies on the barriers to effective prevention and treatment. REACH recommendations include the following:

Reduce sharply the number of persons who have not been HIV-tested in any 12 month period.
Provide HIV tests and appropriate counseling as routine aspects of all healthcare services.
Engage communities and myriad public, private and religious institutions in action programs focused on achieving high and sustained HCT rates.
Take HCT door-to-door using rapid testing methods.
Target the specific barriers to HCT increase shown in REACH studies such as ignorance about risk, assumed cost of drug treatment, confidentiality concerns, and uncertainty about follow-up care.
Develop more effective ways to reach vulnerable youths, especially girls.
Engage political, religious, community and entertainment leaders in high-profile prevention events.
Design innovative approaches to combat stigma.
Commit Nigerian funds over several years to prevention and care so that a greater proportion of expenditures is covered domestically.

Nigeria’s new president, Goodluck Jonathan, has brought renewed dynamism and direction to his country’s federal government. By supporting bold action on HIV/AIDS, he can quickly align Nigeria with other African countries such as Botswana and South Africa that have adopted more aggressive approaches to reversing this relentless pandemic.

Authors

Richard Joseph

Ending Nigeria’s HIV/AIDS Pandemic

Thu, 27 May 2010 09:00:00 -0400

Event Information

May 27, 2010
9:00 AM - 12:00 PM EDT

Saul/Zilkha Rooms
The Brookings Institution
1775 Massachusetts Avenue, NW
Washington, DC 20036

There are currently an estimated 3 million people living with HIV/AIDS in Nigeria, making it the second most infected country worldwide. In light of these stark figures and the general failure by African countries to curb the HIV/AIDS pandemic, how can Nigeria expect to achieve a breakthrough in dealing with its HIV/AIDS epidemic? What policy actions should the global public health community, international donors and the Nigerian government take to help end this health crisis?

The Research Alliance to Combat HIV/AIDS (REACH), a joint collaboration between Northwestern University and the University of Ibadan in Nigeria, has sought to answer these questions. Since 2006, REACH has engaged social scientists in community-based research to explore the attitudes and behaviors related to HIV/AIDS prevention in four Nigerian states and advance strategies to reduce infection rates. On May 27, Global Economy and Development at Brookings and the Buffett Center for International and Comparative Studies at Northwestern University hosted a discussion on REACH’s most recent findings and policy recommendations. The first panel focused on the current state of the epidemic in Nigeria. The second panel examined a preventative approach to HIV/AIDS in Nigeria and other African countries.

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Participants

Panelists

Richard Joseph

Nonresident Senior Fellow, The Brookings Institution
Principal Investigator, REACH
John Evans Professor, Northwestern University

Moderator: Ernest Aryeetey

Senior Fellow and Director, Africa Growth Initiative

Layi Erinosho

President, African Sociological Association

Uche Isiugo-Abanihe

Professor of Demography and REACH Chair, University of Ibadan, Nigeria

Gbenga Sunmola

Principal Researcher, REACH
Research Coordinator, National Agency for the Control of AIDS, Nigeria

Oka Obono

Principal Researcher, REACH, University of Ibadan

Johnnie Carson

Assistant Secretary of State for African Affairs
U.S. Department of State

Moderator: Jacques van der Gaag

Senior Fellow and Co-Director, Center for Universal Education

Phillip Nieburg

Public Health Epidemiologist, REACH
Senior Associate, Center for Strategic & International Studies

Nkem Dike

Associate Project Director, REACH, Northwestern University

Rationally and Effectively Combating Malaria Through Diagnostics

Jessica Cohen — Fri, 23 Apr 2010 12:05:00 -0400

Increasing evidence shows that a large fraction of people who seek treatment for malaria don’t have the disease. A recent randomized trial in Kenya that I conducted with Pascaline Dupas and Simone Schaner uncovered that less than 40 percent of older children and adults who purchase antimalarials from drug stores actually have malaria. Several other non-randomized studies have found similar rates of over-treatment in health clinics and hospitals. These and other studies are telling us that any rational strategy aimed at fighting malaria will have to incorporate diagnostic tools in addition to traditional approaches.

Therefore, as World Malaria Day approaches, I’d like to bring attention to diagnostics—a tool that has been evidently stashed at the bottom of the malaria control toolkit. It is certainly less saliently linked to malaria mortality than bed nets or antimalarial medicines, but its lowly status is arguably at the heart of the inadequate coverage levels of both of these life-saving tools.

The great majority of people treated for malaria in Sub-Saharan Africa self-diagnose and buy medicine from a drug store or pharmacy, bypassing the formal health care system altogether. Many others are treated for malaria in health centers based on clinical symptoms such as fever, as blood tests are extremely rare. Often, the symptoms are the result of a cold, virus or possibly a bacterial infection like pneumonia yet are treated with antimalarial medications.

So what’s the harm in treating someone for malaria when they don’t have it? There is little danger to the individual, because the side effects are moderate. The harm stems from the false impression that they actually have the disease. Erroneous beliefs about malaria can lead to all of the harmful “irrational” behavior that we observe in malaria-endemic populations. Many people continue to not sleep under bed nets, to buy ineffective or sub-standard antimalarials and to take partial, incomplete doses of their regimen. One explanation for low usage of these life-saving tools is that it is difficult for people to learn their benefits when so much uncertainty exists about what is and what is not malaria.

Some argue that such massive overtreatment has fueled the emergence of parasite resistance to previous generations of antimalarials and that limiting overtreatment could help stem resistance to the only remaining effective medicines. What is certain is that this confusion about when an illness is actually malaria has ripple effects, weakening maternal and child health programs and wasting precious millions in foreign aid for malaria control.

Technological innovations in the form of rapid diagnostic tests (RDTs) for malaria have made diagnosis a possibility for remote populations with poor access to quality health care. RDTs are blood tests that give results in 15 minutes and many brands are reliable and easy to use. Before RDTs, a person had to have access to a health facility with a working microscope and a lab technician. Several recent studies with community health workers have found that RDTs can be used effectively by people without formal medical training. Pharmacists could also be trained to administer RDTs to customers.

Malaria diagnostics do not only benefit those stricken with malaria. For example, pneumonia remains a leading cause of death among children under five. Because fever is a common symptom of pneumonia, children are often first presumptively treated for malaria. Only when their symptoms don't improve are other possible causes explored. Pneumonia can progress quickly in children and thus eliminating the possibility of malaria early allows the exploration of other potential diagnoses.

As with so many public health products, developing the technology and increasing access is not enough. Psychological barriers must be reduced as well. In our Kenya study, 65 percent of people who tested negative for malaria went on to buy the medicine anyway. More research into how adherence to test results can be improved is needed and increased access to RDTs will need to be coupled with better information about the importance of malaria diagnosis.

In several months, the Global Fund to Fight AIDS, TB and Malaria is spearheading an innovative intervention to increase access to effective antimalarials by heavily subsidizing Artemisinin Combination Therapies (ACTs) in 10 African countries. Without an increase in use of malaria diagnostics, our results from Kenya suggest that a vast amount of that subsidy money will go to antimalarials for people without malaria. The policy is still likely cost-effective—the bulk of malaria morbidity and mortality is from young children and this subsidy should dramatically increase their access to affordable, effective antimalarials. But there is a great opportunity here for subsidy money to be better targeted and for malaria treatment to be more rational by increasing access to diagnostics.

Authors

Jessica Cohen

Image Source: © Thierry Roge / Reuters

Telehealth and Mobile Communications: The New Frontier in Modern Emergency Preparedness

Mon, 19 Apr 2010 10:00:00 -0400

Event Information

April 19, 2010
10:00 AM - 11:30 AM EDT

Falk Auditorium
The Brookings Institution
1775 Massachusetts Ave., NW
Washington, DC

The aftermath of the earthquake in Haiti revealed how new “telehealth” technologies and mobile communications can literally be the difference between life and death when large-scale disaster strikes. While interest in these innovations has increased at the state and federal level, real-world use of, and investment in, these emergency management tools has been limited.

NOTE: The audio for this event is truncated at the very beginning, due to technical difficulties.

On April 19, the Brookings Institution hosted a policy discussion on how health technology, mobile communications and telehealth can spur more efficient and effective care for disaster survivors, as well as better equip first responders. The event also focused on the investment required to support a technologically enhanced emergency preparedness system. Darrell West, Brookings vice president and director of Governance Studies, moderated a panel of disaster relief and emergency management experts including Alexander Vo of the University of Texas at Galveston, Marion Orr of Brown University, and Joe Becker of the American Red Cross.

After the program, panelists took audience questions.

Audio

Telehealth and Mobile Communications: The New Frontier in Modern Emergency Preparedness

Transcript

Transcript (.pdf)

Event Materials

20100419_telehealth

Participants

Moderator

Panelists

Alexander Vo

Executive Director, AT&T Center for Telehealth Research and Policy
University of Texas at Galveston

Marion Orr

Director, A. Alfred Taubman Center for Public Policy and American Institutions
Brown University

Joe Becker

Senior Vice President, Disaster Services
American Red Cross

Tackling HIV/AIDS in Africa: From Knowledge to Behavior Change

Richard Joseph — Wed, 04 Nov 2009 13:48:00 -0500

There is greater frankness today about development policy failures in Africa. It was reflected in President Barack Obama’s speech in Accra, Ghana on July 11 when he stated: “Development depends on good governance. That is the ingredient that has been missing in far too many places for far too long.” And it is also seen in President Jacob Zuma‘s surprising declaration to the South African Parliament on October 29 for the need to “respond with urgency and resolve” to the “devastating impact of HIV and AIDS” on the nation.

It has taken many years for a South African president to speak frankly to his fellow citizens of the need to convert “knowledge into behavior change.” Unlike his predecessor, Thabo Mbeki, who refused to acknowledge how HIV was actually transmitted, Jacob Zuma now encourages South Africans to learn their HIV status and “take informed decisions to reduce their vulnerability to infection.” While estimates of new infections in South Africa are an astounding 750,000, they are also climbing relentlessly in Nigeria where latest annual estimates are put at 370,000.

In January 2006, the Bill & Melinda Gates Foundation made a large grant to support the Research Alliance to Combat HIV/AIDS (REACH), a collaborative program between Northwestern University and the University of Ibadan, Nigeria. Survey research has been completed in 12 communities in four Nigerian states on two projects: the social and cultural factors that influence vulnerability to infection and the willingness, or inhibition, regarding the use of testing and care facilities. A third pilot project on adolescents and HIV prevention was started when preliminary findings showed the high vulnerabilities of, and insufficient attention being devoted to, this age group.

This month, teams of REACH researchers will return to the twelve communities to report on the research findings. These studies could not have been conducted without the active cooperation of local authority figures: government, traditional and religious. In spring 2010, comprehensive reports of the three projects, along with policy recommendations, will be made available in Nigeria and internationally.

The four Nigerian states in which the REACH research was conducted—Oyo, Lagos, Cross Rivers and Benue—have prevalence rates of 2.2, 5.1, 8 and 10.6 percent, respectively. Understanding the reasons for these disparities requires probing the economic, cultural, normative and other factors involved. Even with this information, inducing the necessary remedial action must overcome great barriers.

One of the notable achievements of this era has been the provision of billions of dollars annually so that millions of HIV-infected persons worldwide can receive anti-retroviral drugs. However, a report just published predicts that unless there are drastic changes in infection rates, tackling AIDS and its consequences in poor countries could cost $35 billion annually in two decades.[1] Since sub-Saharan Africa still accounts for two-thirds of persons infected with HIV, much more vigorous efforts are needed to curb transmission of the disease in the continent.[2]

President Zuma told South Africans that “knowledge will help us to confront denialism and the stigma attached to the disease.” That is no easy charge after decades of disinformation and distrust. I was confounded in a tour of our research sites in Nigeria earlier this year when a man in one community complained that, as a result of drug treatment, it was now difficult to know who was infected and therefore whom to avoid. In that remark, knowledge, stigma, and behavior were tightly interwoven. Unwinding them to facilitate effective and humane action will require enhanced collaboration, at the level of communities, among government, social, religious, business and academic actors.

Richard Joseph is Principal Investigator of REACH.

[1] Donald G. McNeil, Jr., “Panel warns that without new direction, epidemic will remain out of control at 50,” New York Times (November 2, 2009).

[2] For a strategy of wider testing and earlier drug treatment in Washington, DC and the Bronx, whose prevalence rate of about 5 percent is close to the Nigerian average, see Susan Okie, “Fighting H.I.V., a Community at a Time,” New York Times (October, 27, 2009).

Authors

Richard Joseph

1000 Days to the 7th Billion Human: What Do We Tell Her?

Hakan Altinay — Mon, 26 Oct 2009 00:00:00 -0400

We have roughly 1,000 days before the seventh billion human being joins the rest of us on Planet Earth. A worthwhile exercise would be for each of us to take 15 minutes as we ride the bus to work, run on our tread mill, or sip our coffee, and imagine what we would say to our seventh billion fellow human being about the human condition awaiting her. This conversation, however hypothetical, can help us take stock of the global constellation that we all have helped produce.

The first thing we could tell our newcomer is that she can expect to live in excess of 70 years, and that this is twice as long as what people counted on a century ago. We would tell her that while the world is a very unequal place in terms of income and wealth, disparities in life expectancy are decreasing. We could report in good conscience that the world possesses some effective global public health instruments, and that we have eradicated small pox and might see the end of polio and malaria in her lifetime. She could be told to expect to have more than 11 years of schooling, education being another area where gross but diminishing disparities loom large in the world. We could also report that the world which awaits her prizes gender equality more than any other era, so she can anticipate a more enabling world than her mother or grandmother endured.

In the spirit of first giving the good news, we can in good faith report that she will have capabilities which can not only empower her but would have been the envy of emperors and tycoons from earlier centuries. In terms of information and knowledge, our newcomer will have unprecedented access through the likes of Wikipedia, JSTOR, and Google Scholar. The breadth of information and knowledge and the ease of her access would have been unfathomable to the Encylopédistes and Academies of Sciences of previous centuries.

At the same time, we should admit to her that there are critical risks. Although we know about the mind-numbing results of previous genocides and have profusely sworn not to allow this ultimate crime to take place again, the sad fact is that if our seventh billion fellow human were to face genocide, chances are that nobody will come to her rescue. We would need to tell her that not only the able military powers of the world have abdicated their solemn responsibility to protect, but that they have also not allowed the development of institutions for people to join a UN Volunteer Army.

We would also need to tell her that we have set into motion, first unknowingly and for the last 20 years in full realization, a chain of events which will soon become irreversible and will lead to catastrophic consequences through climate change. We would need to add that while we were able to devise a scheme for collective global action to prevent ozone depletion, a similar framework to contain climate change has eluded us.

More importantly, working on a welcome message to our seventh billion fellow human being provides us with a rare but overdue opportunity for introspection as well as a frank accounting of the implicit responsibilities we have toward other human beings and future generations. The contours of our epic interdependence should be evident to many of us by now. What is less apparent is our working answer to what our responsibilities are toward each other and what, in turn, our rights are. Without some notion of global civics, the waters of interdependence are treacherous to navigate. Doing unto others what we would have others do unto us remains the most resilient benchmark for decent conduct in human history. This hypothetical conversation with our newcomer could set us on a path toward answering some to these cardinal questions.

Authors

Hakan Altinay

Publication: The Huffington Post

How Computer Modeling Can Stem the Spread of Influenza

Joshua M. Epstein — Tue, 18 Aug 2009 15:50:36 -0400

Experts are bracing for an extremely high H1N1 flu infection rate this fall and winter. Joshua Epstein, director of the Center on Social and Economic Dynamics, says computer modeling can help the medical community and policy-makers predict which populations are most susceptible to infection, how great the infection rate will be and how to stem the spread of the virus.

TRANSCRIPT

"At the moment we are trying to calibrate these models to existing data on prior pandemics and using the best available estimates of what this disease would look like – that is to say in consultation with the Centers for Disease Control, the National Institutes for Health and other agencies. Of course it is not clear how quickly flu could mutate into a very serious disease so we expect something like a 30% attack rate which is a high level of disease. We are talking about tens of millions of cases worldwide. But, again, the main issue is whether it will mutate into a form more severe than we’ve seen and whether we can develop a well-matched vaccine to that disease, whether people will adhere to distancing measures – to stay home from school, stay home from work and so forth. So that number (the 30% attack rate) assumes business as usual, no interventions, no social distancing, no travel restrictions, none of the things that we would impose so we hope to do way better than that but its needs to understand that if we don’t do those things it could be very severe."

"...Classical epidemic modeling uses differential equations and assumes very well-mixed populations with no particular diversity in the susceptible, or the infected, or recovered groups. Our version of modeling is called agent-based computational modeling and we, basically, build artificial societies of individuals who have different levels of susceptibility, can go through different stages of the disease, can adapt their behavior, can exist in social networks that we try to capture, so much more of the social richness and behavioral realism is captured in our form of modeling than in classical epidemiology. Although classical epidemiology has given us wonderful and deep insights about disease progression, about the non-linear tipping behavior of epidemics and has also given tremendous insight into what vaccination strategies should be focused on achieving."

"...You would never base policy on a particular run of the model or a particular evolution. You run these things many, many times and build up a robust statistical portrait of how the disease might progress and address your policy to that. But we know a lot about how people move around – better in the United States than in less-developed countries – but in the U.S. we have good data on movement from zip code to zip code, the distribution of trips by distance, we know a lot about international air travel – we have that completely programmed into our models. So we have good idea how people would move around in a day-to-day, business-as-usual scenario. What is a lot less clear is how people will adapt their behavior under the stress and fear of a large-scale epidemic. And we are seeing, in India for example at the moment, rapid spread of fear itself. And we’ve seen this before. There is a famous incident in 1994 in Surat, India where 300,000 people evacuated Surat, a city in India, out of fear of pneumonic plague and in the end not a single case was confirmed by the World Health Organization. This is also an issue."

Video

Modelling to Contain Pandemics

Joshua M. Epstein — Thu, 06 Aug 2009 12:00:00 -0400

As the world braces for an autumn wave of swine flu (H1N1), the relatively new technique of agent-based computational modelling is playing a central part in mapping the disease's possible spread, and designing policies for its mitigation.

Classical epidemic modelling, which began in the 1920s, was built on differential equations. These models assume that the population is perfectly mixed, with people moving from the susceptible pool, to the infected one, to the recovered (or dead) one. Within these pools, everyone is identical, and no one adapts their behaviour. A triumph of parsimony, this approach revealed the threshold nature of epidemics and explained 'herd immunity', where the immunity of a subpopulation can stifle outbreaks, protecting the entire herd.

But such models are ill-suited to capturing complex social networks and the direct contacts between individuals, who adapt their behaviours — perhaps irrationally — based on disease prevalence.

Agent-based models (ABMs) embrace this complexity. ABMs are artificial societies: every single person (or 'agent') is represented as a distinct software individual. The computer model tracks each agent, 'her' contacts and her health status as she moves about virtual space — travelling to and from work, for instance. The models can be run thousands of times to build a robust statistical portrait comparable to epidemic data. ABMs can record exact chains of transmission from one individual to another. Perhaps most importantly, agents can be made to behave something like real people: prone to error, bias, fear and other foibles.

Read the full article at Nature.com»

Video

Authors

Joshua M. Epstein

Publication: Nature

The Swine Flu Outbreak and its Global Economic Impact

Warwick J. McKibbin — Mon, 04 May 2009 11:06:13 -0400

Editor's Note: The swine flu, caused by a strain of the influenza virus common in pigs and having symptoms similar to that of influenza, continues to grow in the U.S. and globally. Fearing this outbreak may lead to pandemic, stock markets have declined and tourism, food and transportation industries are suffering from a lack of public confidence. Warwick McKibbin, nonresident senior fellow, compares the global response to the early stage of swine flu outbreak to other infectious disease outbreaks in recent history—including SARS and avian flu—and analyzes the impact on the global economy.

Q: With the world in an economic recession, how have global reactions differed in response to the swine flu from other infectious disease outbreaks in recent history?

Global reactions have been consistent with previous flu outbreaks. Stock market values of industries that are likely to be affected have declined. People have started to change their behavior and spending patterns. Policy responses have been better as earlier outbreaks have demonstrated that early response is critical.

Q: How have past disease outbreaks strengthened the global health system?

Earlier outbreaks have caused authorities in many countries to develop pandemic response plans, which have recently been activities by the WHO listing the current outbreak at level 5. These plans have been informed by past experience. The one lesson that has not been learnt is the most important: that the major source of the pandemic potential is the levels of poverty in developing counties and the quality of health care systems in these economies. This aspect of global health care system reform is badly lacking critical investment.

Q: For both investors and consumers, what lessons can be learned from past outbreaks?

It is not the deaths or the periods away from employment that cause economic activity to decline during a pandemic. It is the disruption to markets caused by a loss of confidence and a change in spending patterns driven by fear. Secondly the shock, although it can be significant, is over relatively quickly.

Q: How have the U.S. and global economies been affected by the early stage of the swine flu outbreak?

In our study from 2006 we explored four different scenarios: mild, moderate, severe, and ultra. The differences are driven by the epidemiological assumptions about attack rates and the case fatality rates. Currently there is not enough information to know which scenario is evolving but the mild scenario appears the most likely given current information. The initial economic adjustment occurs through falls in equity markets especially for the most affected industries such as tourism, travel and sectors with a high reliance on human contact. Travel plans are already changing and airline bookings are being affected.

Q: How can this outbreak lead to further economic decline?

The next few weeks are critical. If the disease is declared a pandemic and the case fatality rate worsens and mild panic begins to appear then the real economy will start to bear the brunt of the disease outbreak. We estimated in our study that a mild scenario would cost the global economy about $360 billion and an ultra scenario up to $4 trillion within the year of the outbreak. This is not good news for a global economy trying to emerge from a severe economic contraction caused by the global financial crisis.

Authors

Warwick J. McKibbin

Containing the Spread of Swine Flu and Other Diseases through Dynamic Modeling

Tue, 28 Apr 2009 12:00:00 -0400

When cases of swine flu rose in the United States and around the world in 2009, health officials took action to contain the spread and severity of the disease. Ross Hammond discussed the artificial society models he helped develop that can aid professionals in better understanding how to prepare for and react to epidemics.

Transcript

"This has the potential to be scary. It’s a frightening downside if this gets more serious. At the moment, the indications are that it’s fairly limited to the United States. I think I would encourage everyone to pay close attention, to keep abreast of the latest news, and to follow any instructions they may receive from the public health authorities who really are on top of this. A lot of our research shows that even the best public policies that we have available can be undermined if people are unaware of what they are supposed to be doing or don’t follow the directions they are given. So, I think that’s quite important, but at the moment no one is being asked to do anything in most of the United States except to be vigilant, and I think that makes sense."

"...This particular epidemic caught everyone in the public health community by surprise, a little bit, because we were prepared for an avian flu – a so called H5M1 flu – and this is actually a fairly different virus, and we are still learning more about it and how it behaves and we have to retool our models for that. But, at CSED what we do is we build artificial society models where we are able to, on computers, reconstruct some of the dynamics of an epidemic and understand a little bit better what kinds of interventions might be effective and how people should best respond."

"...There have been some careful estimates done for an avian pandemic flu of what the macroeconomic costs could be. If it were a really severe flu, like the one we had in 1918, the Congressional Budget Office estimates that it could affect GDP by as much as four percent. At the moment that doesn’t seem usually likely because as I say it’s been fairly limited in the U.S., but if it were take a turn for the worst that’s certainly a possibility. Those economic costs come partly in the form of decreased demand as everyone stays home, doesn’t go shopping, doesn’t go out to eat, and also partly in the form of productivity losses — people who call in sick or need to stay home to care for a loved one. So that’s a real possibility, but we hope it doesn’t come to that."

"...A lot has changed since 1918, for better and for worse actually. We certainly have a lot more information at our fingertips, we have done a lot more study and preparation. It’s also the case that the transportation networks are very — it’s a much more connected world than it was in 1918, and that’s actually a disadvantage because it means that something like a flu can spread very rapidly around the world, so we have to be vigilant to prevent against that occurring. I would say that what we have learned from studying 1918 is that timing is really important in all sorts of public health interventions – both when you put something like a quarantine or travel restrictions or school closings in place and when you lift it. And there is some evidence in 1918 that they didn’t apply these measures fast enough or they lifted them too early and this can lead to multiple waves of infection, so we would like to avoid that. I think there is very close attention being paid to deploy these interventions the moment they become necessary."

What a Flu Pandemic Could Cost the World

Alexandra A. Sidorenko and Warwick J. McKibbin — Tue, 28 Apr 2009 12:00:00 -0400

Comparing the recent outbreak of swine flu to the influenza epidemic of 1918-19 may seem premature. A century ago, 50 million died -- a mortality rate far, far higher than this current strain has seen so far. Yet while today's modern world is much better prepared to deal with a public health emergency, in one respect, it is in fact more vulnerable to contagion. The integrated nature of the global economy means that international finance offers little resistance to the economic shocks that accompany pandemics.

Even with a relatively small number of cases and deaths, the global cost of a modern epidemic is large and not limited to the countries directly affected. Outbreaks inspire massive drops in the consumption of various goods and services (think tourism and group recreation); they increase businesses' operating costs, and they speed the flight of foreign capital. The SARS epidemic in 2003 offers a telling example. As flights were cancelled, schools shut down, and panic gripped Asian markets, the relatively short-lived outbreak cost the world $40 billion.

In 2006, we estimated the likely global economic consequences of an influenza pandemic using several epidemic scenarios. The study began with a multi-country, multi-sector, dynamic model capable of describing the trade and financial linkages between and within economies. We then fed the model with a series of shocks meant to simulate the effect of pandemic: a decreased labor force, increased business costs, a shift in consumer preferences due to social distancing, and changes to risk premiums. We took into account the geography of each region and the strength of its health system. Labor supply shocks varied depending on the infection rate and mortality in a given country.

Even a mild pandemic, we discovered, would likely make a noticeable dent in global economic output. The mild scenario, estimated to cost the world 1.4 million lives, reduces total output by nearly 1 percent or approximately $330 billion (in constant 2006 prices) during the first year. In our model, as the scale of the pandemic increases, so do the economic costs. A massive global economic slowdown occurs in the next-worst scenario, with more than 142 million people killed and some output in economies in the developing world shrinking by half. The loss in output in this scenario could reach $4.4 trillion, 12.6 percent of global GDP in the first year. Of course, the composition of the slowdown would differ sharply across countries, with a major shift of global capital from the affected economies to the less-affected safe havens of North America and Europe.

In the most severe scenario, cost shocks play a much larger role in the GDP losses. Markets close down entirely. Wealth and income effects are larger in developing countries, and the contraction of demand is therefore much larger than in Europe and North America (Japan is caught in the middle). The destructive cycle feeds itself; Worse epidemiological outcomes in poorer countries perversely send much-needed capital flowing out and into industrialized economies. This exacerbates the current-account positions of the receiving countries and puts downward pressure on developing-country exchange rates. In essence, entire developing markets could become junk assets. World trade would likely contract significantly.

So far, our real-world swine flu pandemic appears to be less severe than the dire scenarios used in our modeling. But even now, the global economy is seeing some troubling signs of capital retreat. The Mexican peso, for example, has taken a hit. And just five days after news of the outbreak, it looked likely that Mexico's government would have to tap its $47 billion credit line with the International Monetary Fund.

Although stocking Tamiflu and developing vaccines might be the most pressing priorities of the day, it will take a much longer, sustained effort to prevent a future financial catastrophe. Investing in poverty reduction and healthcare in developing countries are the keys to managing pandemics in the long term. For now, we will have to live with a world where a relatively minor flu outbreak in Mexico City can send markets reeling in Tokyo.

Authors

Alexandra A. Sidorenko
Warwick J. McKibbin

Publication: Foreign Policy - The Argument

A Case Study of Aid Effectiveness in Ethiopia

Getnet Alemu — Tue, 28 Apr 2009 10:34:00 -0400

Introduction

Foreign aid has played a major role in Ethiopia’s development effort since the end of World War II. It has been instrumental in bridging the country’s savings-investment and foreign exchange gaps. Its importance as a source of financing for the development of capacity building (human capital, administrative capacity, institutional building, and policy reforms) is also unquestionable. Thus, increasing efforts were made to mobilize foreign aid in the last two regimes. Following the change in political regime in 1991 and the adoption of the structural adjustment program in 1992/93 in particular, the country has enjoyed a significant amount of aid. A large and growing inflow of concessionary loans and grants has occurred since 2001, following the issuance of the first poverty reduction strategy paper (known as the Sustainable Development Poverty Reduction Program) from 14 multilateral sources—mainly IDA, EC, the Global Fund, and the African Development Fund and more than 30 bilateral sources—mainly the USA, UK, Italy, Canada, Germany, Ireland, Japan, Netherlands, Norway, and Sweden.

Ethiopia has been one of the major recipients of international aid in recent times. According to OECD-DAC statistics, net ODA to Ethiopia amounted to US$1.94 billion in 2006, making it the 7th largest recipient among 169 aid receiving developing countries. In absolute terms, the amount of ODA has risen sharply from an average of $881 million per annum in the second half of the 1990s to over $1574 million per annum for the first half of the 2000s. Over the last seven years (2000-2006), ODA has averaged at $1683 million per year. The average contribution of bilateral donors to ODA over the eight year period was $322.4 million per year accounting for 31 percent of ODA. In the 1990s, some 49 percent of the total net ODA was in the form of multilateral aid. This was slightly reduced to 46 percent for 2000-2006, reflecting the increased importance of non-multilateral sources. Figure 1 presents the recent annual flows of foreign aid to Ethiopia.

As shown, the flow of net ODA actually declined from 1992 to 2000 and sharply increased in 2001 with a modest increase onwards. The main driving force for donors to resume their assistance was the issuance of the Sustainable Development Poverty Reduction Program in 2001/02. Of these significant net ODA flows, the contribution of the World Bank’s support through the soft windows of IDA was tremendous. In 2001 alone it was 38.7 percent of the total net ODA. Since 1993, the Bank has committed a total of $3.1 billion to Ethiopia. Ethiopia receives about $8.0 per capita from IDA. This makes Ethiopia the largest IDA borrower in Africa and the fifth largest in the world. In addition, the Bank has coordinated a consortium of donors to support the economic reform program.

It is also enlightening to examine the magnitude of ODA in relation to the local economy (Table 1). As can be seen from Table 1, the share of ODA increased from 1996 to 2002 and is on a declining trend since then. The growth of the economy since 2003 might have been the cause for such decline. In 2006, ODA flows account for about 48 percent of the gross national savings, 40 percent of gross domestic investments, 58.5 percent of overall government expenditure, and 10 percent of the GNI of the country. Although there was an increasing ODA inflow, the savings-investment gap was as high as 20 percent of GDP, leaving a huge gap to be bridged by non-ODA inflows.

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Authors

Getnet Alemu

Reform of How Health Care Is Paid for in China: Challenges and Opportunities

Sat, 22 Nov 2008 12:00:00 -0500

Editor's Note: China's current strategy to improve how health services are paid for is headed in the right direction, but much more remains to be done. In a recent article in The Lancet, Brookings scholars David de Ferranti and Maria-Luisa Escobar, along with Shanlian Hu, Shenglan Tang, Yuanli Liu, and Yuxin Zhao, examine key challenges that need to be met and explore lessons from other countries. This article is the sixth in a series of seven papers on health system reform in China.

Introduction

To implement the ambitious strategy that China is now rolling out to improve its health system, several key challenges need to be met. One challenge is already being resolved: the central government’s spending on health, after languishing for many years at exceptionally low levels compared with that in other countries, is now being increased substantially.3 Other financial and systemic issues include reversal of the upward spiral in the out-of-pocket payments that households pay to get health services; achievement of adequate financial protection for the entire population through insurance or other prepaid coverage; control of the rapid escalation of health-care costs; curtailment of inefficiencies and reducing waste; improvement of the quality of care; and enhancement of equity, including addressing disparities among China’s diverse regions.

These challenges affect global health, not only because China’s 1·3 billion people comprise a fifth of the world population, but also because its innovations and experiences will be helpful and influential for other countries. China’s renewed quest to modernise its health system is part of a larger process worldwide. If the 20th century was transformed by two great health-related transitions (the demographic revolution that increased longevity and reduced fertility and the epidemiological revolution that reduced the incidence of many infectious diseases), the 21st century may be fundamentally changed by a third great transition in how health care is financed, provided, and organised. Some countries are well advanced in this third transition, having already replaced arrangements in which the cost of health care is borne mainly by the few who get sick, with policies by which cost is shared by all, equitable access to services is assured, and protection against financial ruin because of illness is widespread. But many countries still have a long journey ahead, and their citizens are impatient for faster advances.

In China major steps toward this third transition were made in the four decades after 1949 and the formation of the People’s Republic, but advances then stalled and were partly reversed in subsequent years.4–9 Now China is trying to recover lost ground and finish the job, helped by a strong economic base and a new development policy centred on people rather than economic growth alone.

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Authors

David de Ferranti
Maria-Luisa Escobar
Shanlian Hu
Shenglan Tang
Yuanli Liu
Yuxin Zhao

Publication: The Lancet Vol 372, Issue 9652