Polio Eradication and General Development Questions

I recently posted about the work my brother does for the CDC (Shout Out to the Big Brother) and the Gates Foundation announcing a new initiative on agri-business financing (Food Security and Agri-Business Financing Program from Gates Foundation) and there happens to have been an article last week in the Wall Street Journal related to both of those posts (WSJ: Gates Rethinks His War on Polio).  The article brings up an interesting discussion about the best approach to improving the health of both the developing world and the global population and other questions about the role and effectiveness of international aid in the developing world.

As I had mentioned before one of the three Gates Foundation focus areas is Global Health and the foundation has put up quite a bit of money to eradicate polio.  This is known as a "vertical" approach where a single disease with dramatic symptoms is honed in on with the hopes of dramatically reducing its frequency worldwide and subsequently improving global health (like smallpox was eradicated worldwide in 1979).  Vertical approaches tend to get quite a bit more publicity since they are tangible and generally well-known diseases like HIV/AIDS, cancer, malaria, etc.  On the other hand, "horizontal" approaches are focused on general improvements in the broader healthcare systems of the world and may include water, hygiene, sanitation, access to medicine and medical care, etc.  In the developed world, much of the healthcare infrastructure like clean water sources, hospitals, and availability of medicines is already in place so horizontal policies tend to receive less attention (ignoring the recent major healthcare overhaul in the U.S.).  In the developing world, the existing healthcare systems can be quite shoddy (at best) and there is much more interest in projects that address more basic needs like digging wells to improve the water supply or building clinics to increase availability.

While eradicating polio worldwide is certainly something the international community should continue to pursue (especially when we are so close), it does make you wonder if those resources (~$8.2B over the last two decades) could have been better utilized by addressing the most basic of healthcare needs of the developing world (currently, polio is essentially just a disease of the developing world) like ensuring a clean water supply or improving systems to provide vaccines and medicines.  When Lee returned from his first trip to South Africa during his residency, I remember him telling me that much of his time was spent diagnosing and treating diseases that he had rarely (or never) spent much time with in the U.S. because they were essentially non-existent at home.  While I don't remember exactly what he was treating and imagine some of it was TB and HIV/AIDS related, I would also guess many of the issues were related to broader healthcare issues in South Africa like malnutrition, unsafe drinking water, and lack of preventative medicine.  Of course the effects of vertical and horizontal approaches do cross over (like in the case of malaria-preventing bed nets), but it does make you wonder what is the best way to affect change in the livelihoods of those in the developing world.

Broadly speaking, international aid organizations and non-governmental organizations ("NGOs") have thousands of projects around the developed and developing world with the general goal of improving peoples' lives.  It could be anything from digging wells to financing education to teaching them to produce better products that generate more income (like me!).  Programs might include operating a soup kitchen or training people in new skills or providing temporary financial assistance or housing.  Every project is established with good intentions (one would assume) and strives to further its goals in often challenging environments.  At the same time, aid organizations are put (or put themselves) in the awkward position where in order for a project to succeed, the ideals, work ethic, goals, etc. of the organization often must be embraced by (or imposed on) the people that the project is trying to effect.

This brings up some questions about the best way to provide assistance to those in need and the role of aid organizations in the developing world:

• Which projects have the greatest impact on the livelihoods of the people?
• Do the people impacted by these projects really want the projects in the first place?
• What social, political, logistical, and financial challenges exist locally that could impact the project's success?
• In the developing world, is it outsiders' place to alter societal social norms for the assumed betterment of society?  
• Should the developed world force its perception of success on those who may be both poor and happy?

While there are no answers to these questions, there is a constant debate about what type of aid is the most effective as there are a variety of theories on how to get the most bang for your development buck.  I am far from an expert on this whole discussion but am very happy that I have had the opportunity to better understand it by living in East Africa.

On a side note since malaria in the developing world is a hot topic, I recently wrote about the heavy rains during the Rwandan rainy season and the impressive rain water management system that has been built here.  This remarkable drainage system, along with the generally high elevation of the country, has dramatically reduced the prevalence of malaria, especially when compared to neighboring countries.  There isn't that much standing water in Rwanda and it can get quite cool here (low 50s) so the environment is just not that conducive to supporting a large population of Anopheles mosquitoes that carry malaria.  This is why Lucy and I do not take any malaria prophylaxis like malarone, lariam, or doxycycline when in Rwanda (though we did take it on our recent trip to Zanzibar).  As of now we are still malaria free!