The War of the Causes in Aid

The development industry seems to be riddled with people whose main job is to divert money to their good cause. The advocates are united by a strong belief in the priority that should be given to their sector (education, water, AIDS etc). They convince themselves that they are speaking for real interests of the poor… Within many aid agencies there is a permanent state of low intensity bureaucratic warfare for resources…{staff} fight to defend and expand funding for the causes they work on. They deliberately stoke up pressure in private alliances with civil society organisations – many of whom they fund – to raise the political stakes through conferences, international declarations, and publications with the aim of committing funders to spend a larger share of aid resources on their issue.  ….But for the aid budget as a whole these are zero sum games, and everyone would be better off – and many lives would be saved – if it stopped.

This quote comes from a blog post by Owen Barder which is now several months old. For some reason we’re just seeing it now, but thought it was still worth sharing with our readers too.

He gives AIDS in Ethiopia as an uncomfortable example of this kind of advocacy distorting aid:

According to the World Health Organisation (WHO), in Ethiopia about 65% of the population (52 million people) live in areas at risk of malaria. Malaria is the leading cause of health problems, responsible for about 27% of deaths; and malaria epidemics are increasing. The HIV/AIDS prevalence rate among adults is 2.1% (2007) – that’s about 1.6 million people living with HIV.

Of $5.15 per head provided in aid for health to Ethiopia in 2007, about $3.18 per head was earmarked for HIV  while about $0.26 cents per head was allocated to malaria control.  Given the relatively low burden of HIV, earmarking 60% of health aid for HIV is excessive relative to other needs for health spending.

Of course it is right that we should try to make sure that everybody with HIV has access to medicines to keep them healthy, and … to prevent spread of the disease. But we should also make sure that people have bednets and drugs to stop malaria, provide childhood vaccination to prevent easily preventable diseases, ensure access to contraception and safe abortions, and, above all, enough funding to provide basic health services that would save thousands of lives and suffering.  Yet we are not willing to provide enough money to do all of this.  It is in this context that it is damaging to earmark 60% of health aid to HIV.

Owen is equally blunt about the way forward:

we should, as a development community, heap scorn and opprobrium on anyone caught advocating for more resources in their sector.  We need stronger social norms in development that frown upon this kind of anti-social behaviour.

A Tale of Two Refrigerators

In 2001 in southern Sudan, it was a time of peace between wars. It was a time ripe for treating diseases that kill thousands of children every year. It was an opportune time for measles vaccination to halt outbreaks of one of the world’s most preventable diseases. The Measles Initiative, founded by the WHO, UNICEF, the CDC and the American Red Cross, was created to address this significant challenge. In the rural county where I ran an NGO, over 1,200 young children died of measles over four months in early 2001. The death toll was devastating to our school children and their families: local villagers did not have the resources to combat the outbreak except to bury the dead.

When we reported the outbreak to the WHO, the officials we corresponded with expressed shock and dismay that our communities had no access to a vaccination program to stop the spread. But the WHO was caught in a Catch-22 of their own devising: they were unwilling to allocate resources and send doctors unless they could be certain the outbreak was measles, but they couldn’t be certain it was measles without a clinical diagnosis by qualified medical personnel.

Our NGO shipped out videotape of the infected children to one of the Measles Initiative partners. A medical doctor and global measles expert said the video was some of the best footage of children with measles he’d ever seen, but unfortunately Sudan wasn’t on the list to have a measles eradication program that year and he couldn’t be certain without seeing the patients. Even with the clear video footage, a senior WHO official still wouldn’t attribute the children’s deaths to measles nor send an investigative team. So, as far as we know, the children who died in eastern Upper Nile state in 2001 were never counted in the WHO’s official measles statistics.

Worse yet, the WHO wouldn’t supply vaccines to inoculate children and stop the outbreak without a refrigerator to store them, and the remote communities where we worked had no refrigerator and no reliable power source. UNICEF, we were told, would provide a fridge if the number of diagnosed deaths from measles was significant. But with no qualified medical personnel to diagnose a “significant” number of deaths in our area, we didn’t qualify.

In cooperation with Save the Children (US) and funded by USAID, our NGO set up a medical clinic and put qualified African medical staff in place. Training on running a vaccination program was provided and record-keeping started. The communities waited impatiently for the vaccination program as more children died in subsequent outbreaks. There were hundreds more deaths diagnosed from measles each time. Our NGO was repeatedly told it was “near the top” of the waiting list, but years passed with no refrigerator and no vaccines.

Another outbreak of measles started in mid-2008. In desperation, our NGO raised private funds to purchase a refrigerator and fly it into the isolated area where we worked. Within a few months, our new refrigerator was in place and ready to hold the free vaccines that the Measles Initiative promised to qualified organizations. We have found that “free” is a relative term in Africa, however. We quickly learned that a small number of vaccines were available to us at a regional distribution center, a $5000 air charter flight away.

Just last week, a second refrigerator was delivered, this time courtesy of Save the Children (US), nearly seven years after the original request was made. According to locals, thousands of children have died of measles in the mean time, but the major aid agencies still cannot work together to provide truly free vaccines. Seven years later, this community has two empty refrigerators and still no means to keep their children dying from measles. The refrigerator excuse is gone but the vaccines are effectively out of reach.

Even a time between wars is not the best of times for the poor in rural Sudan. As it turned out, it has been a time of bureaucratic “defer and delay” from the UN aid agencies who failed to provide the vaccines needed to save vulnerable children dying from a preventable disease. After seven years, Save the Children (US) is making the most progress, which is disappointingly slow.

It makes me wonder if the 90% drop in measles infection rate between 2000 and 2006 claimed by the WHO is accurate, or if the children who are dying are just too much trouble for them to count.

Did Bill and Melinda Gates Claim Malaria Victories Based on Phony Numbers?

Tuesday’s Financial Times printed a Martin Wolf interview with the Gateses from Davos, available as a video on the FT web site. A sample quote from the interview:

We’re trying to make sure that people understand this: aid is effective…So, for instance, malaria incidence is down in countries such as Zambia, Ethiopia, and Rwanda. It’s down in some countries by over 50 percent and some by 60 percent…[if we and other donors] come in and distribute mosquito nets – 60m to date – that is how we have achieved these declines. So we are able to say, “Look, aid is making a huge difference, we are literally saving people’s lives."

Real victories against malaria would be great, but false victories can mislead and distract critical malaria efforts. Alas, Mr. and Mrs. Gates are repeating numbers that have already been discredited. This story of irresponsible claims goes back to a big New York Times headline on February 1, 2008: “Nets and New Drug Make Inroads Against Malaria,” which quoted Dr. Arata Kochi, chief of malaria for the WHO, as reporting 50-60 percent reductions in deaths of children in Zambia, Ethiopia, and Rwanda, and so celebrated the victories of the anti-malaria campaign. Alas, Dr. Kochi had rushed to the press a dubious report. The report was never finalized by WHO, it promptly disappeared, and its specific claims were contradicted by WHO’s own September 2008 World Malaria Report, by which time Dr. Kochi was no longer WHO chief of malaria.

(There was never a retraction in the New York Times, so perhaps Mr. and Mrs. Gates can be forgiven for being confused – although with most of the world’s public health professionals on Mr. and Mrs. Gates’ payroll you would think their briefers would have access to the most accurate information.)

The September 2008 WHO Malaria Report keeps Rwanda as a success story (along with some other new success stories – not mentioned in the New York Times – like Sao Tome & Principe and Zanzibar), but Zambia and Ethiopia are gone: the effects of malaria control in Zambia were “less clear,” and in Ethiopia, “the expected effects” of malaria control are “not yet visible.”

Digging deeper into the WHO Malaria Report, the standards for data on malaria are set so low, it is even more striking how the Kochi numbers – those numbers that fueled a February 2008 New York Times story and a February 2009 Gates claim – failed to meet even these low standards. The WHO says (in a small print footnote): “in most countries of Africa, where 86% cases occur, reliable data on malaria are scarce. In these countries estimates were developed based on local climate conditions, which correlate with malaria risk, and the average rate at which people become ill with the disease in the area.” Another stab at explanation of their malaria numbers was: “From an empirical relationship between measures of malaria transmission risk and case incidence; this procedure was used for countries in the African Region where a convincing estimate from reported cases could not be made.” (Possible translation: we make the numbers up.)

The shakiness of the numbers is visible when you look at them by country in the WHO Malaria Report. For the “success story” of Rwanda, there is an estimate of 3.3 million malaria cases in 2006, with an upper bound of 4.1 million and a lower bound of 2.5 million. But wait – another way to estimate cases, which is the one used to estimate trends, shows 1.4 million cases in 2006 (and this was an increase over the 2001-2003 average). Estimates of child malaria deaths in Rwanda are similarly all over the place – they do show a drop from 2001 to 2006, but the change is dwarfed by the vast imprecision conveyed by the lower and upper bounds.

In another WHO success, Zanzibar (which, to be fair, Mrs. Gates also mentioned as a success by in the interview), there seems to be more consensus on success from a combination campaign featuring indoor spraying of homes, insecticide-treated bed nets, and treatment of malaria patients with advanced drugs. It seems to be easier to make inroads into malaria on small islands. The American Journal of Tropical Medical Hygeine has published two articles suggesting there was success of malaria control in Sao Tome (also an island) and a corridor in South Africa, Mozambique, and Swaziland, apparently using more rigorous data methods.

As far as the country claims by the WHO and Mr. and Mrs. Gates, however, there seems to be mass confusion, and data that ranges from phony to made-up to shaky, about what interventions are responsible for what trends where. The WHO Malaria Report offers this ringing conclusion in its “Key Points” summary on how to control malaria:

In general, however, the links between interventions and trends remain ambiguous, and more careful investigations of the effects of control are needed in most countries.

Maybe the Gates Foundation should be funding more rigorous data collection. With all this effort to fight the tragedy of malaria, it’s even more tragic that the malaria warriors can’t even get accurate reports of who is sick and dying when and where.