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A More Holistic Approach to Improving the Human Condition

Last week, I ran across an interesting article in the Wall Street Journal about the stumbles Bill Gates’ venerable $700 million effort to help eradicate Polio has taken in Africa. The Bill & Melinda Gates Foundation is recognized as the largest charitable institution in history and perhaps the most important as well. Time Magazine recognized Bill and Melinda as the Most Important Persons of the Year in 2005 for their charitable work. This is why the recent stumbles are such an eye opener.  The Bill and Melinda Gates Foundation is a smart organization with deep financial and technological resources.  If they can’t do it, who can?

Here is an excerpt of the Wall Street article:

Bill Gates walked into the World Health Organization’s headquarters in Geneva—for a meeting in an underground chamber where global pandemics are managed—and was greeted by bad news. Polio was spreading across Africa, even after he gave $700 million to try to wipe out the disease.

That outbreak raged last summer, and this week a new outbreak hit Tajikistan, which hadn’t seen polio for 19 years. The spread threatens one of the most ambitious health campaigns in the world, the effort to destroy the crippling disease once and for all. It also marks a setback for the Microsoft Corp. co-founder’s new career as full-time philanthropist.

Next week, the organizations behind the polio fight, including WHO, Unicef, Rotary International and U.S. Centers for Disease Control and Prevention, plan to announce a major revamp of their strategy to address shortcomings exposed by the outbreaks.

Polio is a centerpiece of Mr. Gates’s charitable giving. Last year the billionaire traveled to Africa, one of the main battlegrounds against the disease, to confer with doctors, aid workers and a sultan to propel the polio-eradication effort.

“There’s no way to sugarcoat the last 12 months,” Bruce Aylward, a WHO official, told Mr. Gates in the meeting in the underground pandemic center last June. He described how the virus was rippling through countries believed to have stopped the disease.

Mr. Gates asked: “So, what do we do next?”

That question goes to the heart of one of the most controversial debates in global health: Is humanity better served by waging wars on individual diseases, like polio? Or is it better to pursue a broader set of health goals simultaneously—improving hygiene, expanding immunizations, providing clean drinking water—that don’t eliminate any one disease, but might improve the overall health of people in developing countries?

The new plan integrates both approaches. It’s an acknowledgment, bred by last summer’s outbreak, that disease-specific wars can succeed only if they also strengthen the overall health system in poor countries.

If successful, the recalibrated campaign could shape global health strategy for decades and boost fights against other diseases. A failure could rank the effort as one of the most expensive miscalculations in mankind’s long war with disease. Already, polio has evaded a two-decade-long, $8.2 billion effort to kill it off.

Big donors have long preferred fighting individual diseases, known as a “vertical” strategy. The goal is to repeat 1979’s victory over smallpox, the only disease ever to be eradicated. By contrast, the broader, “horizontal” strategy has less well-defined goals and might not move the needle of global health statistics for years.

The polio fight is a lesson for Mr. Gates’s foundation, which is funding other vaccines that could face similar setbacks. In the polio fight, his foundation backed a program that was following an outdated playbook. Polio’s resurgence last year forced a major rewrite.

The shift on polio was informed by Mr. Gates’s trip last year to Nigeria, a nation with a history of exporting the virus to other countries. Mr. Gates was accompanied by a Wall Street Journal reporter.

Just as Mr. Gates introduced himself to the sultan, the lights flickered out.

“I want to welcome you to the real world—to the real third world,” the sultan said to Mr. Gates from his gilded chair in the darkened room.

Men like the sultan are important allies. … But he, too, questioned the wisdom of targeting one disease. “Other health issues should be looked into,” the sultan said, “instead of just facing one direction with polio eradication.” He ticked off tuberculosis, HIV and AIDS, malaria, cholera and a parasitic infection known as “snail fever.”

After the global victory over smallpox 30 years ago, a rush of energy went into similar “vertical” attacks on single diseases. The polio program followed that approach and made great gains. Led by WHO and donors such as Rotary, the campaigns by the year 2000 slashed the world’s polio cases to under 1,000 from 350,000 in 1988. Polio fighters planned to eradicate the disease by 2000.

That date came and went. But polio persisted, eating up billions of dollars.

Critics argued for a shift away from killing polio to free up money for controlling multiple diseases. In some countries, polio campaigns became an example of a functioning vaccination system even as other diseases were missed. Mr. Gates saw that himself in Nigeria.

Arriving at a Sokoto health clinic in a Toyota minivan stocked with Diet Coke, Mr. Gates stepped inside and was soon leaning on a wooden desk, flipping through children’s vaccine records. “Do you know if this child had the first dose of DPT?” he asked, pointing to a record of a diphtheria vaccination of a boy who appeared to have missed a treatment. A health worker beside him didn’t have an answer.

The clinic also had no hepatitis B and yellow fever vaccines, the workers said, because the government’s system for supplying medicine wasn’t working.

By contrast, in front of the clinic, a polio campaign was in full swing. Health workers tended coolers filled with vials of vaccine for children gathered there.

At a meeting the next day in the capital, Abuja, Nigeria’s head of primary health care, Dr. Muhammad Ali Pate, reopened the vertical-vs.-horizontal debate. Even if Nigeria lowers polio cases, he said, the gains “can’t hold” without a broader health-care system, he said.

In many respects, Mr. Gates remains a tech geek at heart. Aboard his plane, he expounded on an array of scientific topics: From developments in genotyping, to research showing that Bangladesh’s high disease-immunity rates are due to “oral-fecal” transmission (when people build immunity by ingesting contaminated food or water).

In Nigeria, Mr. Gates scored a diplomatic triumph. He won commitments from the sultan, and from Nigeria’s governors, to take a more active role in polio vaccinations. “We really stand at the threshold of global health success on polio,” he told the assembled governors at the close of the trip.

However, just three days later, a new front opened 2,000 miles away in Uganda. There, a woman walked into a hospital to say her son couldn’t move his left leg. It was Uganda’s first polio case in 12 years.

In August, experts commissioned by the WHO landed in Angola, Pakistan, Afghanistan, India and Nigeria to evaluate the polio program. In Africa, a team found that once polio had been ended in some countries, weak health-care systems let it return. In northern India, bad sanitation, malnutrition and other intestinal issues are believed to hurt the oral polio vaccine’s effectiveness.

These findings echoed the message to Mr. Gates in Nigeria, and marked a turning point among the Gates Foundation and other backers of the polio fight in the debate over whether the strictly “vertical” polio strategy could succeed.

Reading this article helps to remind me just how difficult improving the human condition really is.  As Gates is learning, while technology and money are powerful forces to bring about change, broader economic and societal changes must also occur to bring about substantive, lasting improvements in the human condition.

Sometimes, I do wonder, whether people in developed countries truly understand the multi-dimensional challenges facing the people of the developing world.  It is human nature to try to force-fit the world into their world view.  [For example, I still remember my first efforts trying to learn English by pronouncing English using Chinese tones. ;-)] But doing so in trying to understand people sharing dramatically different circumstances can lead to ignorance and misunderstanding.

People in the developed world naturally face very different problems than those in developing world.  Not every problem in the world can be cast as a lack of vaccination, a problem in rule of law, as a lack of human rights, lack of democracy, lack of freedom of this and that.

Just this week, I came across this NY Times article critical of the way China has continued to deal with Nigeria despite its domestic political turmoils.  Here is an excerpt:

Just a few months ago, China was widely derided here as the financial backbone propping up an autocratic president, Mamadou Tandja, giving him the confidence to ignore international condemnation as he chopped away at Niger’s democratic institutions.

But now that Mr. Tandja has been overthrown, China appears to be settling into a new role: business partner to the good-government-preaching military officers who ousted Mr. Tandja under the banner of restoring democracy.

“Our diplomatic relations with China were not affected by the coup d’état,” said Mahaman Laouali Dan Dah, a spokesman for the military junta now running the country.

That was plain to see from the front page of the government newspaper this month. China’s ambassador to Niger, Xia Huang, was prominently shown inspecting the bridge that his country is building here in the capital. About 10 days before, Mr. Xia had proclaimed on state television that China’s extensive oil and uranium interests in Niger had not been “disrupted by the events” — the coup — in February, news agencies reported.

There may still be some small perturbations. The junta has said broadly that it may adjust any deals made by Mr. Tandja to ensure that they sufficiently benefit Niger, a nation rich in uranium and, potentially, oil.

But the junta does not seem eager to upset the Chinese — “checking doesn’t mean calling into question,” said Col. Abdoulkarim Goukoye, a junta member — and for now China appears to be proceeding confidently, sealing its reputation here as the continent’s behind-the-scenes force, ready to do business regardless of who is in power or whatever outrage exists about it.

“They couldn’t care less” who leads the country, Mohamed Bazoum, a former opposition leader recently appointed by the junta to a civilian council, said of China’s investments in Niger. “The Chinese, they were about to destroy democracy. They were playing a very negative role.”

But even Mr. Bazoum did not suggest breaking with China now. In a sign of how desperately Niger needs investment — the nation ranks at the very bottom of the United Nations human development index — Mr. Bazoum said he hoped the old deals would be respected, suggesting how quickly the looming backlash against China here has become an embrace.

France, the former colonial power here, has also been criticized by opposition leaders for not speaking out forcefully enough against Mr. Tandja, and the largely state-owned French nuclear engineering giant, Areva, has two uranium mines here, with plans for a third.

But last year, as Mr. Tandja dissolved Parliament and the nation’s highest court, France adhered to the European Union’s suspension of aid to Niger, a penalty enforced by the United States as well. The suspension has hurt the junta, too, because it remains in effect until new elections are scheduled.

China, by contrast, has stayed the course. Cash flowed from a substantial fund established by the Chinese, allowing Mr. Tandja to continue paying salaries as Western support ebbed. Now that he is gone, work has continued on a giant Chinese-built oil refinery in the nation’s east.

The people of Niger “are eyewitnesses to the benefits of the friendship between the two countries,” Mr. Xia said earlier this month, according to Xinhua, the Chinese state-run news agency.

In the capital, the Chinese presence is still visible: groups of Chinese working on the new bridge, crowding the departure lounge at the airport, behind the normally closed gates of the sprawling Chinese economic mission downtown.

Mr. Tandja had openly sanctified the presence of his new friends, in a speech that captured their singular position. “Today, we work with the Chinese, and you can easily identify them,” Mr. Tandja told a gathering near the oil fields in December. “Any presence here other than the Chinese should be brought to our attention immediately. Remain vigilant.”

Then, for five days after Mr. Tandja was overthrown, the Chinese companies exploring for oil in the north and east ceased operations, only to resume right after that, workers there said. The symmetry of interests continued, even after Mr. Tandja’s fall.

The NY Times article cast China’s pervasive and reliable presence in Niger as something bad. Why are the Chinese there; is the local government legitimate; is the government fairly elected; which government is less corrupt; which government is more “for the people.”

The truth is that there is no way a common citizen in the West can make the judgment.  (Does the common Western even know where Niger is, and what its capital is called?)  So they judge with what they know – which is with poor information – and using the political rhetoric they know. Thus the NY Times get wrapped up with agonizing over the existence of some dissent – where convenient (call me a skeptic) – while forgetting the people as a whole.

This is a disservice. For example, where as Polio may be the problem if it occurs in the developed world, it may be only a symptom of the problems when it occurs in the developing world. If Polio breaks out in the developed world, the eradication of Polio ends the problem. When Polio breaks out in the developing world, it is probably only symptomatic of the multitude of problems facing populations in those part of the world.  What are needed are substantive, broad-breath, measurable push to improve the human condition – through the building of roads, schools, hospitals, the creation of jobs, etc. – not heroic pinprick solutions where do-gooders from the rich world can swoop in as humanitarians and swoop out as heroes.

One may be critical of Mr. Tandja or Mr. Bazoum or the junta or even the whole governing structure of Niger. But bickering about politics through Western eyes will not improve the lives of the Niger people.

The “vertical system” to improving human condition is bankrupt.  It is myopic, ineffective, and easily corrupted.

I am glad the Chinese have stayed in Niger. Not everything is perfect in Niger today, but if Nigerans keep developing its economy – together with the help of their Chinese brethren – things will improve.  Living conditions will improve, education will improve, public health will improve, and in the end – politics, too, will improve.

On a side matter: I hope you enjoy this little video of the song “Lean on Me” by Bill Withers from YouTube, summarizing the main theme I want to get across:

  1. r v
    May 1st, 2010 at 13:06 | #1

    Niger’s case is a good example that “business” (political non-interference) is not a strong factor in whether a country’s government can or cannot change from within.

    The corollary may also be true, that strong external political interference might not affect significant political change within a country.

    Niger’s dictator might be able to buy stuff or borrow money from China, but that doesn’t necessarily increase his political strength at home. (even if he pays off his military officers, they still overthrew him).

    *The human condition, at least, must be changed from within.

    The same lesson can be applied to Iraq and Afghanistan. (which is why I am still very pessimistic about all the money US dumped into the deserts).

  2. May 1st, 2010 at 14:25 | #2

    Bill Withers – Lean On Me (from Tudou.com)

  3. Yiyi Lu
    May 2nd, 2010 at 07:27 | #3

    Dear Allen and YinYang,

    Thank you for your comment on my blogpost on the China Real Time Report website and for introducing me to your blog. I have enjoyed your articles.

    Best wishes,

  4. May 2nd, 2010 at 10:51 | #4

    Hi Yiyi,

    Welcome to our HH blog. Few weeks ago, we’d also echo’ed Prof. Yao Shujie sentiments about the need for a cool U.S.-China relationship:

    Opinion: Keeping a cool view of the U.S.-China Cooperatition

  5. George Monser
    May 10th, 2010 at 16:46 | #5

    I think this is a good, thoughtful article.

    Regarding: “Thus the NY Times get wrapped up with agonizing over the existence of some dissent – where convenient (call me a skeptic) – while forgetting the people as a whole.”
    I would replace “convenient” with “profitable”. I think the Times is no more money-hungry than average, but they and other newspapers are running scared of following the dinosaurs into extinction.

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