By Jagdish Bhagwati
January/February 2010
Foreign Affairs
An annotated Foreign Affairs syllabus on foreign aid.
Dead Aid: Why Aid Is Not Working and How There Is a Better Way for Africa. By Dambisa Moyo. Farrar, Straus & Giroux, 2009, 208 pp. $24.00.
If you live in the affluent West, no public policy issue is more likely to produce conflicts in your conscience than foreign aid. The humane impulse, fueled by unceasing televised images of famine and pestilence in the developing world, is to favor giving more aid. But a contrasting narrative has the opposite effect: Emperor Jean-Bédel Bokassa of the Central African Republic used Western aid to buy a gold-plated bed, and Zaire's dictator, Mobutu Sese Seko, spent it on personal jaunts on the Concorde. Such scandals inevitably lead many to conclude that most aid is wasted or, worse still, that it alone is responsible for corruption.
These debates have largely been the province of Western intellectuals and economists, with Africans in the developing world being passive objects in the exercise -- just as the 1980s debate over the United States' Japan fixation, and the consequent Japan bashing, occurred among Americans while the Japanese themselves stood by silently. Yet now the African silence has been broken by Dambisa Moyo, a young Zambian-born economist with impeccable credentials. Educated at Harvard and Oxford and employed by Goldman Sachs and the World Bank, Moyo has written an impassioned attack on aid that has won praise from leaders as diverse as former UN Secretary-General Kofi Annan and Rwandan President Paul Kagame.
Moyo's sense of outrage derives partly from her distress over how rock stars, such as Bono, have dominated the public discussion of aid and development in recent years, to the exclusion of Africans with experience and expertise. "Scarcely does one see Africa's (elected) officials or those African policymakers charged with a country's development portfolio offer an opinion on what should be done," she writes, "or what might actually work to save the continent from its regression. . . . One disastrous consequence of this has been that honest, critical and serious dialogue and debate on the merits and demerits of aid have atrophied." She also distances herself from academic proponents of aid, virtually disowning her former Harvard professor Jeffrey Sachs, whose technocratic advocacy of aid and moralistic denunciations of aid skeptics cut no ice with her. Instead, she dedicates her book to a prominent and prescient early critic of aid, the development economist Peter Bauer.
Moyo's analysis begins with the frustrating fact that in economic terms, Africa has actually regressed, rather than progressed, since shedding colonial rule several decades ago. She notes that the special factors customarily cited to account for this tragic situation -- geography, history, social cleavages, and civil wars -- are not as compelling as they appear. Indeed, there are many places where these constraints have been overcome. Moyo is less convincing, however, when she tries to argue that aid itself has been the crucial factor holding Africa back, and she verges on deliberate provocation when she proposes terminating all aid within five years -- a proposal that is both impractical (given existing long-term commitments) and unhelpful (since an abrupt withdrawal of aid would leave chaos in its wake).
Moyo's indictment of aid, however, is serious business, going beyond Africa to draw on cross-sectional studies and anecdotes from across the globe. Before buying her indictment, however, it is necessary to explore why the hopes of donors have so often been dashed.
THE CHARITY TRAP
Foreign aid rests on two principles: that it should be given as a moral duty and that it should yield beneficial results. Duty can be seen as an obligation independent of its consequences, but in practice, few are likely to continue giving if their charity has little positive effect. Beginning in the years after World War II, those who wanted the rich nations to give development aid to poorer ones had to address the challenges of building domestic support for greater aid flows and ensuring that the aid would be put to good use. But their unceasing efforts to produce higher flows of aid have led aid advocates to propose the use of tactics that have ironically undermined aid's efficacy, virtually guaranteeing the kind of failures that understandably trigger Moyo's outrage.
At the outset, aid was principally driven by a common sense of humanity that cut across national boundaries -- what might be called cosmopolitan altruism. Aid proponents in the 1940s and 1950s, such as Gunnar Myrdal and Paul Rosenstein-Rodan, were liberals who felt that the principle of progressive taxation -- redistribution within nations -- ought to be extended across international borders. This led to proposals such as those to set an aid target of one percent of each donor nation's GNP, playing off the Christian principle of tithing (giving ten percent of one's income to the church) or the Muslim duty of zakat (which mandates donating 2.5 percent of one's earnings to the needy).
How was the one percent figure arrived at? According to Sir Arthur Lewis, the first Nobel laureate in economics for development economics, the British Labour Party leader Hugh Gaitskell had asked him in the early 1950s what figure they should adopt as the United Kingdom's annual aid obligation and Lewis had settled on one percent of GNP as a target because he had a student working on French colonies in Africa, where French expenditures seemed to add up to one percent of GNP. Such a target, of course, implied a proportional, rather than a progressive, obligation, but it had a nice ring to it.
The problem was that the one percent target remained aspirational rather than practical. Outside of Scandinavia, there was never much popular support for giving away so much money to foreigners, however deserving they might be. So aid proponents started looking for other arguments to bolster their case, and they hit on enlightened self-interest. If one could convince Western legislatures and voters that aid would benefit them as well, the reasoning went, the purse strings might be loosened.
In 1956, Rosenstein-Rodan told me that then Senator John F. Kennedy, who bought into the altruism argument, had told him that there was no way it could fly in the U.S. Congress. A case stressing national interest and the containment of communism was needed. And so the argument was invented that unless the United States gave aid, the Soviet Union would provide it and, as a result, the Third World might tilt toward Moscow. In fact, the Soviets had already funded the construction of Egypt's Aswan Dam, a project the United States had turned down. The only catch was that if the Cold War became Washington's rationale for giving aid, it was inevitable that much of it would end up in the hands of unsavory regimes that pledged to be anticommunist -- regimes with a taste for gold-plated beds, Concordes, fat Swiss bank accounts, and torture. By linking aid payments to the Cold War, proponents of aid shot themselves in the foot. More aid was given, but it rarely reached the people it was intended to help.
FROM ALTRUISM TO SELF-INTEREST
When the Cold War began to lose its salience, the search began for other arguments to support aid. The World Bank appointed two successive blue-ribbon panels to deliberate on ways of expanding aid flows, the Pearson Commission, in 1968, and the Brandt Commission, in 1977. The group led by former West German Chancellor Willy Brandt, although emphasizing that there was a moral duty to give, fell back nonetheless on an enlightened self-interest argument based on a Keynesian assertion that made no sense at all: that raising global demand for goods and services through aid to the poor countries would reduce unemployment in the rich countries -- an argument seemingly oblivious to the fact that spending that money in the rich countries would reduce unemployment even more.
Other feeble arguments related to immigration. It was assumed that if aid were given wisely and used effectively, it would reduce illegal immigration by decreasing the wage differentials between the sending and the receiving countries. But the primary constraint on illegal immigration today is the inability of many aspiring immigrants to pay the smugglers who shepherd them across the border. If those seeking to reach El Norte or Europe earned higher salaries, they would have an easier time paying "coyotes," and more of them would attempt illegal entry.
Lewis, who was a member of the Pearson Commission, therefore despaired of both the altruistic and the enlightened self-interest arguments. I recall him remarking in 1970, half in jest, that development economists should simply hand over the job of raising aid flows to Madison Avenue. Little did he know that this is exactly what would happen 20 years later with the advent of the "Make Poverty History" campaign, supported by Live Aid concerts and the sort of celebrity overkill that many Africans despise. Of course, this has meant the revival of the altruism argument. Aid targets have therefore returned to the forefront of the debate, even though they are rarely met: in 2008, there was a shortfall of $35 billion per year on aid pledged by the G-8 countries at the Gleneagles summit in 2005, and the shortfall for aid to Africa was $20 billion.
One of the chief reasons for the gap is not just miserliness but a lack of conviction that aid does much good. Aid proponents today try to overcome this doubt by linking aid-flow obligations to worldwide targets for the provision of primary education and health care and other laudable objectives enshrined in the 2000 UN Millennium Development Goals (which are uncannily reminiscent of the Brandt Commission's proposals). But the question Moyo and other thoughtful critics properly insist on raising is whether aid is an appropriate policy instrument for achieving these targets.
And so one returns to the old question of what Rosenstein-Rodan termed "absorptive capacity": How much aid can be absorbed by potential aid recipients and transformed into useful programs? Arguments that aid can and should be used to promote development seem reasonable but have run into problems -- not just because corrupt dictators divert aid for nefarious or selfish purposes but because even in reasonably democratic countries, the provision of aid creates perverse incentives and unintended consequences.
The disconnect between what development economists thought foreign assistance would achieve and what it has actually done is best illustrated by a close look at the earliest model used to formulate development plans and estimate aid requirements. The model was associated with two world-class economists, Roy Harrod of Oxford and Evsey Domar of MIT. In essence, the Harrod-Domar model used two parameters to define development: growth rates were considered a function of how much a country saved and invested (the savings rate) and how much it got out of the investment (the capital-output ratio). Aid proponents would thus set a target growth rate (say, five percent per annum), assume a capital-output ratio (say, 3:1), and derive the "required" savings rate (in this case, 15 percent of GNP). If the country's domestic savings rates fell below this level, they reasoned, the unmet portion could and should be financed from abroad.
Economists also assumed that aid recipients would use fiscal policy to steadily increase their own domestic savings rates over time, thus eliminating the need for aid entirely in the long run. With such matching efforts by the recipients to raise domestic savings, so the logic went, aid would promote growth and self-reliance.
The problem with this approach, widely used throughout the 1970s, was that although aid was predicated on increased domestic savings, in practice it led to reduced domestic savings. Many aid recipients were smart enough to realize that once wealthy nations had made a commitment to support them, shortfalls in their domestic efforts would be compensated by increased, not diminished, aid flows. Besides, as Moyo notes, the World Bank -- which provided much of the multilateral aid flows -- faced a moral hazard: unlike the International Monetary Fund, which lends on a temporary basis and has a "good year" when it lends nothing, the World Bank was then judged by how much money it disbursed, not by how well that money was spent -- and the recipients knew this.
PAVED WITH GOOD INTENTIONS
Similar problems involving the mismatch between intentions and realities are present in today's battles over aid. Now, as before, the real question is not who favors helping the poor or spurring development -- since despite the slurs of aid proponents, all serious parties to the debate share these goals -- but rather how this can be done.
Many activists today think that development economists in the past neglected poverty in their quest for growth. But what they miss is that the latter was seen as the most effective weapon against the former. Poverty rates in the developing countries did indeed rise during the postwar decades, but this was because growth was sporadic and uncommon. And that was because the policy framework developing countries embraced was excessively dirigiste, with knee-jerk government intervention across the economy and fears of excessive openness to trade and foreign direct investment. After countries such as China and India changed course and adopted liberal (or, if you prefer, "neoliberal") reforms in the last decades of the century, their growth rates soared and half a billion people managed to move above the poverty line -- without question, the greatest and quickest progress in fighting poverty in history.
Neither China nor India, Moyo points out, owed their progress to aid inflows at all. True, India had used aid well, but for decades its growth was inhibited by bad policies, and it was only when aid had become negligible and its economic policies improved in the early 1990s that its economy boomed. The same goes for China.
If history is any guide, therefore, the chief weapon in the "war on poverty" should be not aid but liberal policy reforms. Aid may assist poor nations if it is effectively tied to the adoption of sound development policies and carefully channeled to countries that are prepared to use it properly (as President George W. Bush's Millennium Challenge program recently sought to do). Political reform is important, too, as has been recognized by the enlightened African leaders who have put their energies into the New Partnership for Africa's Development (NEPAD), which aims to check the continent's worst political abuses.
But unfortunately, despite all these good intentions, if the conditions for aid's proper use do not prevail, that aid is more likely to harm than help the world's poorest nations. This has been true in the past, it is true now, and it will continue to be true in the future -- especially if some activists get their wishes and major new flows of aid reach the developing world simply because it makes Western donors feel good.
Moyo is right to raise her voice, and she should be heard if African nations and other poor countries are to move in the right direction. In part, that depends on whether the international development agenda is set by Hollywood actresses and globetrotting troubadours or by policymakers and academics with half a century of hard-earned experience and scholarship. In the end, however, it will be the citizens and policymakers of the developing world who will seize the reins and make the choices that shape their destiny and, hopefully, soon achieve the development progress that so many have sought for so long.
Dembisa Moyo
Showing posts with label imperialism. Show all posts
Showing posts with label imperialism. Show all posts
Thursday, February 16, 2012
Foreign Aid and Underdevelopment in Africa
By Mathew K. Jallow
The African continent has struggled with chronic poverty and under-development since the advent of political independence more than fifty years, and many Africans view this problem as one of Africa's own making. African development experts and academics have blamed foreign aid for the continued and seemingly intractable development crisis confronting the continent. Africa's war on poverty is perceived as amounting to begging and submissiveness, leading to reforms that have made Africans poorer. The contention among many African experts is that the more the developed north co-operated with the south, the poorer Africa became. And increasingly, even tangible western generosity has failed to impress many Africans. Foreign aid has generally benefited the ruling elites in Africa, by among other things, enabling and perpetuating corrupt governments' hold on power, and by extension, entrenching the pervasive underdevelopment. Over the past five decades, foreign emergency assistance to Africa has helped to avert hardship for many of Africa's poor, but failed to promote any significant economic development. Foreign aid is provided with the conviction that real economic development begins when the emphasis is placed on providing aid to poor rural and urban communities.
Providing assistance to Africa's poor is a noble cause, but the five decades long campaign of aid has turned out to be what one critic called “a theater of the absurd.” To-date, the record of western aid to Africa has been significant, amounting to more than $500 billion between 1960 and 1997, which is the equivalent of four Marshall Plans being pumped into Sub-Saharan African. And today, the national budgets of most Sub-Saharan African countries are dependent on foreign aid for up to eighty percent of the annual budgets. Apart from the relief aid and economic development, foreign aid assistance was also provided to support reforms and policy adjustment programs. And between 1981 and 1991 alone, The World Bank provided $20 billion towards Africa's structural adjustment programs. The purpose of the programs was to make public institutions, government agencies, and bureaucracies in Africa more transparent, effective, efficient and accountable. It is baffling that Africa still suffers from a poverty trap, considering the depth of governments' corruption and the missing billions in export earnings from oil, gas, diamonds and other resources. The idea of foreign aid was compatible with the central theme of economic development, and was accepted as a possible escape from the chronic underdevelopment that is characterized by undeveloped infrastructure and dualistic economies. The persistence of the deplorable economic conditions in Africa has become the primary reason for the relentless search for realistic and durable solutions to the continent's development woes, even as the need for aid is intermittently reinforced by the fact that Africa's underdevelopment is accentuated by periodic global economic recession.
When it was conceived after World War II, U.S. foreign aid was designed to serve two conceptually interdependent, but potentially conflicting set of goals: first, the diplomatic and strategic goals that advance U.S. short-term political and long term strategic interests; and secondly, the development and humanitarian goals that sought a long-term economic growth, political stability, and the short-term alleviation of suffering. The U.S. Foreign Assistance Act of 1973 stressed the need to promote equity, minimum standards of living and per capita growth. Since then, the U.S. foreign assistance statutes have gone through several changes; each with its own objective and some would argue, defined by global politics rather than by any humane consideration. The concept of “Basic Human Needs,” under the U. S. Foreign Assistance statutes, can be seen as paradoxical if one considers the foreign assistance legislation as the expression of the primary function of foreign aid. The position of the U.S. as observed by development experts is that developmental and humanitarian programs received substantial funding only when they coincided with U.S. diplomatic and strategic interests. And despite the massive injection of aid over the past five decades, Africa, rather than achieve economic growth and development, has become more dependent, with standards of living experiencing a net decline. Studies show that there is overwhelming evidence that foreign aid has helped to under-write the misguided policies of the corrupt and bloated government bureaucracies across Africa. The Oxford International Group study revealed that the external stock of capital held by Africans in overseas accounts, was between $700billion and $800 billion in 2005, and nearly 40% of Africa's aggregate wealth was stacked in foreign bank accounts in Europe, United States and Japan. Africa's foreign assistance is significant when we look at the overall economic situation, and African governments have become dependent on aid for the survival of their people and governments.
The concept of aid is relatively new, and it is basically the transfer of resources from the rich countries to poor ones for the purpose of development. Foreign aid is primarily the official government-to-government transfer of financial and technical resources for the programs of social and economic development. The main objective of aid is to produce accelerated economic growth, combined with higher standards of consumption, but as we have seen, aid is very much influenced by prevailing regional or global political climates. Due to political necessities, donors often exert pressure for political and policy reasons, thereby making dependence on aid shaky and unreliable. Additionally, those charged with making decisions on aid allocation, generally do not have a good grasp of issues facing developing and poor countries; consequently, the rationale behind most aid disbursement decisions are usually fraught with poor judgments and inconsistencies. The disadvantages of aid include the fact that funding provided is usually tied to the fact it must be spend in the donor countries regardless of the high cost of goods and services. Rather than create wealth, prosperity and economic development, most Africans have over the past few decades realized a net decline in their standards of living. Research shows that over the period that foreign aid was being pumped into Africa, the per capita GDP declined by an averaged of 0.59 percent annually, between 1975 and 2000. The Heritage Foundation in 1985 concluded that foreign aid is not the answer to Africa's economic troubles; and in fact, the organization maintained that aid was contributing to Africa's underdevelopment woes. It is now a popular belief that foreign aid has been found to do more harm, leading to the situation where Africans have failed to set their own pace and direction of development; free of external interference. The United Nations Conference on Trade and Development admits that aid to Africa has not been successful and despite many years of policy reform, no Sub-Saharan country has completed its adjustment program or achieved any sustained economic growth. Similarly, a Heritage Foundation study found that foreign aid retards the process of economic growth and the accumulation of wealth. The Foundation argued aid dependency pulls entrepreneurship and intellectual capital into non-productive activities, thereby blunting the entrepreneurial spirits of many Africans.
The decades of financial and technical aid transfers to Africa have not fostered economic growth, rather, it has left seventy countries, primarily in Sub-Saharan African, poorer than they were in 1980, and 43 are worst off than they were in 1970. The United Nations Development Program describes the 1980's, the period of highest foreign aid transfer to Africa, as the “lost decade.” Over much of that decade, 100 countries mostly in Africa, suffered major economic decline or net stagnation, and the conclusion is that foreign aid failed to create economic growth in aid recipient countries. The old belief that aid transfer allowed poor countries to escape the poverty trap has been refuted, because research has proved that poverty, contrary to the popular belief, is not caused by capital shortage. In fact, studies show that there is no correlation between aid and economic development, rather, most aid recipient countries have become and remained more dependent of foreign aid. Additionally, a World Bank study showed that food aid budgets in developed nations were mainly guided by prospects for commercial exports of surplus from donor countries, and not determined in accordance with the needs and objectives of recipient countries' to reduce dependence on imported food. Donors reduce food aid budgets when the prospect for commercial exports are good, and increase them when the prospects are poor. A U.S 1997 General Accounting Office report, criticized USAID for having no strategies for the assessment of the impact of its programs in enhancing the food security, and further, the Agency could not determine whether food aid was an efficient means of accomplishing food security goals in aid recipient African countries. Poor policy choices in Africa have caused development there to first stagnate and decline over the past several decades. In 1960, South Korea was as poor as the African countries, but thirty years later, the country was wealthy enough to offer aid to Africa. Altogether, South East Asian countries have achieved phenomenal development in the past five decades, and many have joined the industrialized countries of the world. Critics now contend that foreign aid to Africa must be changed for a number of reasons, but mainly because it has not worked. Further, they argue that most aid initiatives are well thought out, and most of the funding intended for projects, rarely reaches the intended target groups. A study found that in Uganda, less than 30 per cent of the aid earmarked for primary education actually reached the intended schools. The missing funds were stolen, wasted or re-apportioned to priorities identified by politicians or middle level and senior government officials. To address the persistent failure of Sub-Saharan Africa, donors have identified capacity building as the answer to the perennial problem of underdevelopment in Africa. Since 1980, about 4 billion dollars has been spent each year in training, technical assistance and institutional strengthening capacities in Africa.
More than six decades of foreign aid has not changed Africa's latent capacity, moreover, professionals from around the continent are leaving for other countries in the west at an alarming rate. Today, many aid agencies are acknowledging that there is greater pressure to commit money grandly than to spend it wisely in Africa. In 1976, Tanzania began the $220 million Mufundi paper mill factory project financed by the World Bank. The project turned out to be a total failure, yet for twenty years, Tanzanians paid the bill for that ill-thought out experiment. In the early 1990's, the UNDP spent $900,000 over a three year period trying unsuccessfully to show farmers in north-east Ivory Coast how to cultivate onions. Meanwhile, 90 miles north, in neighboring Burkina Faso, the farmers there were growing onions profitably under similar agricultural conditions, but without any foreign aid. A World Bank finding on food import into Somalia in 1998 concluded that aid had methodically undermined Somalia's civil society. Somalia had become more dependent on imported food than any other country in Sub-Saharan Africa. The report noted that until food aid began to arrive in Somalia, the economy was predominantly an agricultural and pastoral economy. And up until the early seventies, Somalia was self-sufficient in food grains production; however, Somalia's share of food imported in total volume of food consumption rose from less than 33 per cent in 1979 to over 63 per cent in 1984. This sea change ironically coincided with the period of highest food aid distribution to that country. By increasing the supply of food aid, Somalia's domestic food prices were dampened, and the prices of local food crops were prevented from rising, thus reducing the incentives for domestic food crop producers. This exacerbated Somalia's food deficit. Mismanagement and corruption in the administration of food aid distribution in Africa is pervasive, in the absence of efficient and accountable institutions to oversee and institute fair and just aid distribution practices. But, critics of aid say donors are also complicit in the failure of aid distribution in Africa, as there are no effective monitoring mechanisms, and this gives the politicians and bureaucrats the opportunity to rob what is intended for the people. A former U.S Ambassador to Ghana, Edward P. Bryan, admitted that foreign donors have allowed what he describes as “a small, clever class that inherited power from the colonial masters to take us to the cleaners.” It will take a lot of resources and time to turn Africa around. In March 1990, a Paris daily, Le Monde wrote, “Every franc given to impoverished Africans, comes back to France or is smuggled into Switzerland by African bureaucrats and politicians.” And critics contend that donor agencies knew or should have known the motivation and activities of corrupt African leaders who spirit away billions into Swiss Banks and other western bank accounts. Even famine relief aid is not spared. As early as the late 1980's, a former head of Medicine Sans Frontiers, Dr. Rory Branman, lamented the failure of aid to Africa, saying, “We have been duped.” The Western governments and humanitarian groups”, he said, have “unwittingly fueled and are continuing to fuel an operation that will be described in hindsight in a few years' time as one of the greatest slaughters of our time.” The World Bank admitted that in most cases Western donors knew that up to 30 per cent of the loans to African countries and governments went directly into the bank accounts of corrupt officials, yet The Bank considered these officials and their governments as partners in development.
But, foreign aid is full of ambiguities and double bottoms. It does not fit neatly into any one of the three ways people are said to go about their material transaction; i.e; coercion, exchange and gift giving. Because it is tied with geo-politics, trade and banking, foreign aid cannot be classified purely as gift-giving. During its first four decades, victory in the Cold War was the compelling and pre-eminent drive in the regime of aid giving. Today, experts have identified the predominant motives for aid giving as strategic socio-political, mercantile, and humanitarian and ethical. Official aid is seldom the tool of altruism alone, because the direction of foreign aid is dictated by political and strategic considerations, much more than the economic needs and policy performance of the recipient. However, the motives behind aid never come in fixed and stable proportions. Perhaps the one safest generalization to make is that foreign aid, when used alone or in combination with other policy instruments, has a unique ability to allow the donors to demonstrate compassion, while simultaneously pursuing a variety of other ulterior motives and objectives. In the U.S, the realization that aid has failed to provide economic growth and development over several decades, prompted the U.S. Government to try different ways of administering its foreign aid. Officials in the Reagan administration promoted direct local participation in the planning, implementation and overall control of projects. And USAID further made efforts to recruit in-country field staffs that are experienced in and sensitive to Africa's development processes and institutions. U.S. government officials recommended that Congress monitor the activities of USAID, but without getting involved in any of the operational decision-making. Yet, this did not address the goal conflict that has created the paradox of foreign aid. Countries receiving foreign aid in amounts that are sufficient to stimulate development along the lines of Basic Human Needs mandate, are precisely the countries that are important to the diplomatic and strategic goals of the United States. A Cato Institute study found little evidence that better targeting and management enabled foreign aid to achieve self- sustaining growth in poor African countries. Additional, the U.S. Congressional Budget Office warned that aid can inhibit the commitment to reforms of even the more responsible African governments, and without reform, aid can reinforce policies that do not further development. The failure of Africa's development assistance has allowed poor countries to delay reform, thereby worsening the underlying problems. Empirical evidence suggests that the greater a country's dependence on aid, the worst the quality of its public institutions. Poverty is a justification for aid, but it is seldom the main criterion used for allocating it.
The public image of foreign aid is of Western beneficence; nevertheless, studies show in some cases, foreign worker remittance to their countries of origin far exceeds the annual aid transfers from some European countries. In 1998, the officially recorded remittance from the Netherlands to forty-two low-income developing countries exceeded U.S. $1 billion; a sum equivalent to 115 percent of Dutch aid to those countries. In the non-oil producing countries in Africa, trade losses between 1970 and 1997, represented almost minus 120 % of GDP. Ironically, the World Bank estimates that the purchasing power in those African countries would be considerably lower in 2010, than they were back in 1997. Foreign aid serves a useful purpose when it is provided to alleviate temporary hardship as in cases of natural disasters such as droughts, but, experience in Africa has proved that aid recipients could easily construe foreign aid as a substitution to their own productivity. Across the continent, food aid has suppressed food production, undermining the prices of local produced foods. Agricultural production has declined significantly, as farmers migrate to urban centers to create a shortage of farm workers and exacerbate food production deficit. A mentioned earlier, a major debilitating by-product of foreign aid to Africa is the culture of corruption that has taken root at every level of every government. Today, corruption has become the way of life in every country in Sub-Saharan Africa, and the theft, bribery and embezzlement of aid, and other government resources are so endemic, they are not considered as crimes. African politicians and government officials have engaged in corruption practices, and a 2004-2005 World Bank Report showed that $148 billion were embezzled out of Africa by politicians and bureaucrats; a significant amount of it being aid and loans earmarked for development activities to benefit Africa's poor. Without transparency, accountability, and good governance, Africa's future will continue to remain bleak.
Mathew K. Jallow; M.A. Public Administration and Non-Profit Management. Mr. Jallow is a Gambian journalist/writer and Human Rights Activist exiled in the U.S.
The African continent has struggled with chronic poverty and under-development since the advent of political independence more than fifty years, and many Africans view this problem as one of Africa's own making. African development experts and academics have blamed foreign aid for the continued and seemingly intractable development crisis confronting the continent. Africa's war on poverty is perceived as amounting to begging and submissiveness, leading to reforms that have made Africans poorer. The contention among many African experts is that the more the developed north co-operated with the south, the poorer Africa became. And increasingly, even tangible western generosity has failed to impress many Africans. Foreign aid has generally benefited the ruling elites in Africa, by among other things, enabling and perpetuating corrupt governments' hold on power, and by extension, entrenching the pervasive underdevelopment. Over the past five decades, foreign emergency assistance to Africa has helped to avert hardship for many of Africa's poor, but failed to promote any significant economic development. Foreign aid is provided with the conviction that real economic development begins when the emphasis is placed on providing aid to poor rural and urban communities.
Providing assistance to Africa's poor is a noble cause, but the five decades long campaign of aid has turned out to be what one critic called “a theater of the absurd.” To-date, the record of western aid to Africa has been significant, amounting to more than $500 billion between 1960 and 1997, which is the equivalent of four Marshall Plans being pumped into Sub-Saharan African. And today, the national budgets of most Sub-Saharan African countries are dependent on foreign aid for up to eighty percent of the annual budgets. Apart from the relief aid and economic development, foreign aid assistance was also provided to support reforms and policy adjustment programs. And between 1981 and 1991 alone, The World Bank provided $20 billion towards Africa's structural adjustment programs. The purpose of the programs was to make public institutions, government agencies, and bureaucracies in Africa more transparent, effective, efficient and accountable. It is baffling that Africa still suffers from a poverty trap, considering the depth of governments' corruption and the missing billions in export earnings from oil, gas, diamonds and other resources. The idea of foreign aid was compatible with the central theme of economic development, and was accepted as a possible escape from the chronic underdevelopment that is characterized by undeveloped infrastructure and dualistic economies. The persistence of the deplorable economic conditions in Africa has become the primary reason for the relentless search for realistic and durable solutions to the continent's development woes, even as the need for aid is intermittently reinforced by the fact that Africa's underdevelopment is accentuated by periodic global economic recession.
When it was conceived after World War II, U.S. foreign aid was designed to serve two conceptually interdependent, but potentially conflicting set of goals: first, the diplomatic and strategic goals that advance U.S. short-term political and long term strategic interests; and secondly, the development and humanitarian goals that sought a long-term economic growth, political stability, and the short-term alleviation of suffering. The U.S. Foreign Assistance Act of 1973 stressed the need to promote equity, minimum standards of living and per capita growth. Since then, the U.S. foreign assistance statutes have gone through several changes; each with its own objective and some would argue, defined by global politics rather than by any humane consideration. The concept of “Basic Human Needs,” under the U. S. Foreign Assistance statutes, can be seen as paradoxical if one considers the foreign assistance legislation as the expression of the primary function of foreign aid. The position of the U.S. as observed by development experts is that developmental and humanitarian programs received substantial funding only when they coincided with U.S. diplomatic and strategic interests. And despite the massive injection of aid over the past five decades, Africa, rather than achieve economic growth and development, has become more dependent, with standards of living experiencing a net decline. Studies show that there is overwhelming evidence that foreign aid has helped to under-write the misguided policies of the corrupt and bloated government bureaucracies across Africa. The Oxford International Group study revealed that the external stock of capital held by Africans in overseas accounts, was between $700billion and $800 billion in 2005, and nearly 40% of Africa's aggregate wealth was stacked in foreign bank accounts in Europe, United States and Japan. Africa's foreign assistance is significant when we look at the overall economic situation, and African governments have become dependent on aid for the survival of their people and governments.
The concept of aid is relatively new, and it is basically the transfer of resources from the rich countries to poor ones for the purpose of development. Foreign aid is primarily the official government-to-government transfer of financial and technical resources for the programs of social and economic development. The main objective of aid is to produce accelerated economic growth, combined with higher standards of consumption, but as we have seen, aid is very much influenced by prevailing regional or global political climates. Due to political necessities, donors often exert pressure for political and policy reasons, thereby making dependence on aid shaky and unreliable. Additionally, those charged with making decisions on aid allocation, generally do not have a good grasp of issues facing developing and poor countries; consequently, the rationale behind most aid disbursement decisions are usually fraught with poor judgments and inconsistencies. The disadvantages of aid include the fact that funding provided is usually tied to the fact it must be spend in the donor countries regardless of the high cost of goods and services. Rather than create wealth, prosperity and economic development, most Africans have over the past few decades realized a net decline in their standards of living. Research shows that over the period that foreign aid was being pumped into Africa, the per capita GDP declined by an averaged of 0.59 percent annually, between 1975 and 2000. The Heritage Foundation in 1985 concluded that foreign aid is not the answer to Africa's economic troubles; and in fact, the organization maintained that aid was contributing to Africa's underdevelopment woes. It is now a popular belief that foreign aid has been found to do more harm, leading to the situation where Africans have failed to set their own pace and direction of development; free of external interference. The United Nations Conference on Trade and Development admits that aid to Africa has not been successful and despite many years of policy reform, no Sub-Saharan country has completed its adjustment program or achieved any sustained economic growth. Similarly, a Heritage Foundation study found that foreign aid retards the process of economic growth and the accumulation of wealth. The Foundation argued aid dependency pulls entrepreneurship and intellectual capital into non-productive activities, thereby blunting the entrepreneurial spirits of many Africans.
The decades of financial and technical aid transfers to Africa have not fostered economic growth, rather, it has left seventy countries, primarily in Sub-Saharan African, poorer than they were in 1980, and 43 are worst off than they were in 1970. The United Nations Development Program describes the 1980's, the period of highest foreign aid transfer to Africa, as the “lost decade.” Over much of that decade, 100 countries mostly in Africa, suffered major economic decline or net stagnation, and the conclusion is that foreign aid failed to create economic growth in aid recipient countries. The old belief that aid transfer allowed poor countries to escape the poverty trap has been refuted, because research has proved that poverty, contrary to the popular belief, is not caused by capital shortage. In fact, studies show that there is no correlation between aid and economic development, rather, most aid recipient countries have become and remained more dependent of foreign aid. Additionally, a World Bank study showed that food aid budgets in developed nations were mainly guided by prospects for commercial exports of surplus from donor countries, and not determined in accordance with the needs and objectives of recipient countries' to reduce dependence on imported food. Donors reduce food aid budgets when the prospect for commercial exports are good, and increase them when the prospects are poor. A U.S 1997 General Accounting Office report, criticized USAID for having no strategies for the assessment of the impact of its programs in enhancing the food security, and further, the Agency could not determine whether food aid was an efficient means of accomplishing food security goals in aid recipient African countries. Poor policy choices in Africa have caused development there to first stagnate and decline over the past several decades. In 1960, South Korea was as poor as the African countries, but thirty years later, the country was wealthy enough to offer aid to Africa. Altogether, South East Asian countries have achieved phenomenal development in the past five decades, and many have joined the industrialized countries of the world. Critics now contend that foreign aid to Africa must be changed for a number of reasons, but mainly because it has not worked. Further, they argue that most aid initiatives are well thought out, and most of the funding intended for projects, rarely reaches the intended target groups. A study found that in Uganda, less than 30 per cent of the aid earmarked for primary education actually reached the intended schools. The missing funds were stolen, wasted or re-apportioned to priorities identified by politicians or middle level and senior government officials. To address the persistent failure of Sub-Saharan Africa, donors have identified capacity building as the answer to the perennial problem of underdevelopment in Africa. Since 1980, about 4 billion dollars has been spent each year in training, technical assistance and institutional strengthening capacities in Africa.
More than six decades of foreign aid has not changed Africa's latent capacity, moreover, professionals from around the continent are leaving for other countries in the west at an alarming rate. Today, many aid agencies are acknowledging that there is greater pressure to commit money grandly than to spend it wisely in Africa. In 1976, Tanzania began the $220 million Mufundi paper mill factory project financed by the World Bank. The project turned out to be a total failure, yet for twenty years, Tanzanians paid the bill for that ill-thought out experiment. In the early 1990's, the UNDP spent $900,000 over a three year period trying unsuccessfully to show farmers in north-east Ivory Coast how to cultivate onions. Meanwhile, 90 miles north, in neighboring Burkina Faso, the farmers there were growing onions profitably under similar agricultural conditions, but without any foreign aid. A World Bank finding on food import into Somalia in 1998 concluded that aid had methodically undermined Somalia's civil society. Somalia had become more dependent on imported food than any other country in Sub-Saharan Africa. The report noted that until food aid began to arrive in Somalia, the economy was predominantly an agricultural and pastoral economy. And up until the early seventies, Somalia was self-sufficient in food grains production; however, Somalia's share of food imported in total volume of food consumption rose from less than 33 per cent in 1979 to over 63 per cent in 1984. This sea change ironically coincided with the period of highest food aid distribution to that country. By increasing the supply of food aid, Somalia's domestic food prices were dampened, and the prices of local food crops were prevented from rising, thus reducing the incentives for domestic food crop producers. This exacerbated Somalia's food deficit. Mismanagement and corruption in the administration of food aid distribution in Africa is pervasive, in the absence of efficient and accountable institutions to oversee and institute fair and just aid distribution practices. But, critics of aid say donors are also complicit in the failure of aid distribution in Africa, as there are no effective monitoring mechanisms, and this gives the politicians and bureaucrats the opportunity to rob what is intended for the people. A former U.S Ambassador to Ghana, Edward P. Bryan, admitted that foreign donors have allowed what he describes as “a small, clever class that inherited power from the colonial masters to take us to the cleaners.” It will take a lot of resources and time to turn Africa around. In March 1990, a Paris daily, Le Monde wrote, “Every franc given to impoverished Africans, comes back to France or is smuggled into Switzerland by African bureaucrats and politicians.” And critics contend that donor agencies knew or should have known the motivation and activities of corrupt African leaders who spirit away billions into Swiss Banks and other western bank accounts. Even famine relief aid is not spared. As early as the late 1980's, a former head of Medicine Sans Frontiers, Dr. Rory Branman, lamented the failure of aid to Africa, saying, “We have been duped.” The Western governments and humanitarian groups”, he said, have “unwittingly fueled and are continuing to fuel an operation that will be described in hindsight in a few years' time as one of the greatest slaughters of our time.” The World Bank admitted that in most cases Western donors knew that up to 30 per cent of the loans to African countries and governments went directly into the bank accounts of corrupt officials, yet The Bank considered these officials and their governments as partners in development.
But, foreign aid is full of ambiguities and double bottoms. It does not fit neatly into any one of the three ways people are said to go about their material transaction; i.e; coercion, exchange and gift giving. Because it is tied with geo-politics, trade and banking, foreign aid cannot be classified purely as gift-giving. During its first four decades, victory in the Cold War was the compelling and pre-eminent drive in the regime of aid giving. Today, experts have identified the predominant motives for aid giving as strategic socio-political, mercantile, and humanitarian and ethical. Official aid is seldom the tool of altruism alone, because the direction of foreign aid is dictated by political and strategic considerations, much more than the economic needs and policy performance of the recipient. However, the motives behind aid never come in fixed and stable proportions. Perhaps the one safest generalization to make is that foreign aid, when used alone or in combination with other policy instruments, has a unique ability to allow the donors to demonstrate compassion, while simultaneously pursuing a variety of other ulterior motives and objectives. In the U.S, the realization that aid has failed to provide economic growth and development over several decades, prompted the U.S. Government to try different ways of administering its foreign aid. Officials in the Reagan administration promoted direct local participation in the planning, implementation and overall control of projects. And USAID further made efforts to recruit in-country field staffs that are experienced in and sensitive to Africa's development processes and institutions. U.S. government officials recommended that Congress monitor the activities of USAID, but without getting involved in any of the operational decision-making. Yet, this did not address the goal conflict that has created the paradox of foreign aid. Countries receiving foreign aid in amounts that are sufficient to stimulate development along the lines of Basic Human Needs mandate, are precisely the countries that are important to the diplomatic and strategic goals of the United States. A Cato Institute study found little evidence that better targeting and management enabled foreign aid to achieve self- sustaining growth in poor African countries. Additional, the U.S. Congressional Budget Office warned that aid can inhibit the commitment to reforms of even the more responsible African governments, and without reform, aid can reinforce policies that do not further development. The failure of Africa's development assistance has allowed poor countries to delay reform, thereby worsening the underlying problems. Empirical evidence suggests that the greater a country's dependence on aid, the worst the quality of its public institutions. Poverty is a justification for aid, but it is seldom the main criterion used for allocating it.
The public image of foreign aid is of Western beneficence; nevertheless, studies show in some cases, foreign worker remittance to their countries of origin far exceeds the annual aid transfers from some European countries. In 1998, the officially recorded remittance from the Netherlands to forty-two low-income developing countries exceeded U.S. $1 billion; a sum equivalent to 115 percent of Dutch aid to those countries. In the non-oil producing countries in Africa, trade losses between 1970 and 1997, represented almost minus 120 % of GDP. Ironically, the World Bank estimates that the purchasing power in those African countries would be considerably lower in 2010, than they were back in 1997. Foreign aid serves a useful purpose when it is provided to alleviate temporary hardship as in cases of natural disasters such as droughts, but, experience in Africa has proved that aid recipients could easily construe foreign aid as a substitution to their own productivity. Across the continent, food aid has suppressed food production, undermining the prices of local produced foods. Agricultural production has declined significantly, as farmers migrate to urban centers to create a shortage of farm workers and exacerbate food production deficit. A mentioned earlier, a major debilitating by-product of foreign aid to Africa is the culture of corruption that has taken root at every level of every government. Today, corruption has become the way of life in every country in Sub-Saharan Africa, and the theft, bribery and embezzlement of aid, and other government resources are so endemic, they are not considered as crimes. African politicians and government officials have engaged in corruption practices, and a 2004-2005 World Bank Report showed that $148 billion were embezzled out of Africa by politicians and bureaucrats; a significant amount of it being aid and loans earmarked for development activities to benefit Africa's poor. Without transparency, accountability, and good governance, Africa's future will continue to remain bleak.
Mathew K. Jallow; M.A. Public Administration and Non-Profit Management. Mr. Jallow is a Gambian journalist/writer and Human Rights Activist exiled in the U.S.
Thursday, September 22, 2011
Borderline Bandits
\Borderline Bandits
Washington has its Beltway Bandits. Seattle now has its own kind of (Canadian) Borderline Bandits benefiting from proximity to the Foundation.Seattle is reaping the benefits of having the world's largest health foundation in its backyard. Eric Sorensen gauges the impact.
The Bill & Melinda Gates Foundation aims to address the most pressing public-health issues around the planet. And in its search for solutions, especially to diseases affecting the poorest people, the world's wealthiest foundation is spending a lot of money close to its Seattle home.
The Fred Hutchinson Cancer Research Center, which last year received $40 million in Gates funding for work on an HIV vaccine, is within walking distance of the foundation's office on Eastlake Avenue. The University of Washington, home of a new global-health department started with $30 million in Gates funding and recipient of another $10 million for AIDS vaccine work, is 10 minutes away on the 70 bus.
The non-profit Program for Appropriate Technology in Health (PATH) has received $850 million in Gates funding over a dozen years. Its new and already bulging office building is in Seattle's Ballard neighbourhood, a kayak paddle down Lake Union's ship canal. The Seattle Biomedical Research Institute (SBRI) has received Gates grants totalling nearly $45 million. Its benefactor will soon be even closer: in 2010, the Gates Foundation is due to move into a new 56,000-square-metre headquarters close to the nearby Space Needle tower.
The local funding recognizes Seattle's growing research prowess, particularly in health problems such as malaria, tuberculosis and HIV/AIDS, and in innovative technological solutions. More than half the Gates donations go into global health, with 15% spent in the Seattle area. Global-health researchers around Seattle have received more than $1 billion since Microsoft co-founder Bill Gates and his wife Melinda started the foundation in 1994. And investment in the region is likely to increase. A $30-billion pledge from investor Warren Buffett last year doubled the foundation's size, so staffing will follow. As the foundation grows, it plans to make its involvement in its current issues "deeper and not broader", according to Melinda Gates.
"The effect of the Buffett gift is now beginning to be felt," says Jack Faris, a former spokesman for the foundation who is now president of the Washington Biotechnology and Biomedical Association.
Key collaborations
"The Seattle area has the capacity to highly effectively collaborate worldwide on complex, important contemporary problems and projects," says Jim Gore, the SBRI's chief operating officer. "Every position, from leadership to all our scientific career levels, we expect to see expand locally and we expect to stimulate growth through our collaborators. I don't think there is a job classification that will be left behind."
Faris and others say the foundation's tapping of local expertise is anything but parochial, as global-health research has been part of the Seattle fabric for decades. The SBRI began studying malaria parasites here 30 years ago and PATH has been around nearly as long. The 'Hutch', as the Hutchinson Center is often called, is a leader not only in cancer research but also in the study of HIV/AIDS and other diseases that compromise the immune system. This has led the Hutch to become the coordinating site for many national and international studies, such as the Women's Health Initiative and the HIV Vaccine Trials Network. The University of Washington is also a notable player, housing the Center for AIDS and STD since 1989.
The region's life-sciences and health researchers have a history of collaboration. This may stem from the city's distance from competitive places such as New York, says Chris Elias, PATH president, or maybe it's what he calls the "Northwest spirit". Whatever the cause, when researchers from the university and from a local biotechnology company needed a Biosafety Level 3 facility, the SBRI provided space and time. "That's the kind of sharing they would not be doing in many places that are hotly competing," says Elias.
Developing solutions
The rapidly increasing number of biotech firms and researchers bring other benefits too. They can collectively push for key policies such as better public education, and the availability of jobs makes it easier to hire researchers with spouses who also work. "The bigger the community gets, the easier it gets to recruit," Elias says.
For PATH, this means high-tech solutions for the low-tech developing world with its poor transport, patchy refrigeration and weak health infrastructure. Not only does it work on low-cost vaccines for malaria and meningitis, it is also working on ways to improve access to vaccines for other conditions, such as hepatitis B.
Until about five years ago, there was usually about a 20-year gap between the United States and the developing world getting access to a vaccine, says Teresa Guillien, a spokeswoman for PATH, which is trying to close that gap. In 2005, PATH got a Gates grant of $107.6 million to work with GlaxoSmithKline Biologicals to complete testing and licensing of the most advanced potential vaccine for malaria.
Gates has also helped fund several products at PATH including single-use, self-disabling syringes, an inexpensive dipstick to test for HIV antibodies and vitamin-fortified rice. A PATH group, led by bioengineer Paul Yager of the University of Washington and working with a local diagnostics company called Micronics as well as other firms, is helping develop a credit-card-sized micro lab that can quickly diagnose blood or stool samples for diseases that cause fever. One of two PATH 'lab on a card' projects, it was among 43 chosen from 1,500 responses to the foundation's Grand Challenges to improve global health in 2003. PATH officials see numerous opportunities for multidisciplinary projects that involve technical work, commercialization, public-health expertise and even industrial design.
In Seattle's South Lake Union area, the SBRI has two recipients of Grand Challenges grants totalling $32.5 million. Parasitologist Stefan Kappe is working on mosquitoes to genetically attenuate the Plasmodium falciparum parasite, which spreads malaria. Patrick Duffy is researching children's immune responses, to learn why some suffer so much more severely than others from malaria. He is also working on a vaccine to block the protein that helps the parasite bond to the placenta and rob the fetus of nutrition.
Rapid expansion
"The number and scope of laboratories in the Pacific Northwest conducting research on global health has expanded substantially over the past five years, and will continue to do so in the near term," says Duffy, crediting Gates support and the other funding it has catalysed. "The Gates Foundation itself seems to be on a growth trajectory so there may be new opportunities in analysis, policy and programme management at the foundation."
Duffy has seen the SBRI branch out, with its project managers helping to translate discoveries into products and providing opportunities for people who achieved success in biotech companies and now want to go into non-profit areas. "This is a great opportunity for them in the Seattle area and elsewhere," Duffy says.
Julie McElrath, a Hutchinson researcher, is lead investigator on a $30-million grant to study ways to enhance the cellular immune response generated by HIV vaccines. She talks about the need for scientists who have moved into business, earning either a law degree or MBA, and has seen many staff scientists come from industry. "They understand what it takes to develop a product better than a standard research scientist," she says. "They understand how to work with milestones."
Complex skill sets are needed to meet the Gates Foundation's requirement that researchers share data and collaborate in real time. Its new $287-million HIV/AIDS consortium, for example, has 165 researchers working in 16 teams. Analysing much of its data is Steven Self, head of the Hutchinson Center's Statistical Center for HIV/AIDS Research and Prevention. Self and his colleagues are leading a project to create a repository of statistical data on vaccine candidates being tested within the research network.
The network is likely to produce a wealth of connections and collaborations "that otherwise might never be made", he says. This creates opportunities for database statisticians, mathematical modellers thinking about dynamical systems, and statisticians focused on complex, multidimensional immunological data.
"There are not just more positions of the usual sort," says Self. "There is a wider variety of positions that we're looking for, to solve a wider variety of problems." These are some of the biggest problems in the world and, with support from the Gates Foundation, Seattle is helping to look for innovative solutions.
Eric Sorensen is a science writer based in Seattle.
Subverting National Health Agendas: the new colonialism
March 2011,
Bill Gates with his wife Melinda.
It is time now for a reality check. India is on the priority list for the world's largest private grant-making charity. A search for keyword 'India' on its website throws up 1336 results - of which 57 relate to grants and ongoing projects. In comparison, search for 'China' yields just 117 results.
The size of the projects in India ranges from about 50,000 dollars to 20 million dollars. A bulk of this mega funding is going for work related to new vaccines, technologies and approaches to disease control and prevention. All the funding is routed through a bunch of US-based organisations like the International AIDS Vaccine Initiative, Program for Appropriate Technology in Health (PATH), World Bank and a few universities (Columbia, John Hopkins, American). Gates' grants come attached with strings, making demands on sovereign governments to change their public policies.
Let's see how this is happening. The Foundation selects diseases as well partners to be funded. This selection process is not transparent and is handled not by epidemiologists (so it is not based on dominant disease patterns) but by people who were previously employed with management consultancies and drug companies.
By selecting a disease, a technology to tackle it (vaccine, drug, implant), commercial partner (drug and vaccine makers) and target group for the intervention, the Foundation is effectively making key policy decisions about a country's health programmes.
For instance, Gates wants India to use a vaccine for diarrhea and is rooting for newly developed vaccine product. Is it not for India's health ministry to decide whether it wants to tackle diarrhea through a technological fix - a vaccine - or through public health approach of providing clean water and sanitation? Not only that, Gates is using recipient countries like India to test new vaccines, drugs and approaches. Field trials on social acceptance of HPV vaccine is an example. He is also pushing a costly and controversial pentavlent vaccine, which multinational pharma companies have been lobbying for a long time.
He is even funding a market research study on assess 'willingness (of the poor) to pay' for oral rehydration salts (ORS)! It is amazing how Gates has surreptitiously become a part of India's formal public health policy making apparatus as well.
His nominees "advise the Minister of Health and Family Welfare and senior officials of the Ministry on strategies to achieve key objectives" of the UPA's flagship programme - the National Rural Health Mission (NRHM). They are member of a so-called International Advisory Panel which itself was born as a result of a grant of $661,244 Gates gave to Columbia University. One of the foundation's largest recipients is the Public Health Foundation of India (PHFI) - which is charged with developing public health capacity in the country. It has received grants totaling a whopping $33 million. And Gates got three seats on policy making body of PHFI. Now this number is reduced to two, as one of the Gates nominees Rajat Gupta had to resign from both PHFI and Gates Foundation following charges of insider trading in the US.
The Gates charity is by no means a benign giver, but is an ambitious attempt to create a global health governance system which promotes big pharma and which is accountable to none.
Social Justice, Medical Aid, and Acupuncture.
from the excellent blog Catalyst for Breakfast
Social Justice, Medical Aid, and Acupuncture. Part 1: Voluntourism
Since I will be taking a four month trip to learn about traditional Thai and Chinese medicine in Thailand next year, I have been pondering the significance of medical volunteer work abroad. What is the goal of medical service in other countries? Why do we volunteer in other areas when there are certainly people in need of free medical services in our own countries, states, cities and communities? It can seem like the flight of fancy of a privileged class of practitioners, or an extension of the colonial or missionary mindset, but on the ground what does it offer to the travelers and to the communities they work with?
Travel can teach people about different cultures and can open their minds to new ways of acting in the world, but traveling is a privilege and should be recognized as such. In the case of medical-practice-based traveling, at least the traveler can offer something in return for the opportunity to live in a new place for a short period of time. What kind of “return” does this look like in practice?
This thorough 2009 qualitative study summarizes some of the conundrums of global health and international medical volunteer work: Perceptions of short-term medical volunteer work: a qualitative study in Guatemala(1). The entire article is worth a thorough working-over, but here I provide the general background, minor discussion and conclusions:
…..There is growing interest among healthcare providers in the field of global health; over 25% of all 2008 United States (US) medical school graduates participated in global health experiences during medical school. Beyond medical school, there are countless opportunities for physicians to volunteer their services abroad in resource poor countries, frequently in the form of medical missions that last for a week or two at a time. Several editorials in the medical and social sciences literature have raised important questions about potential unintended consequences of such short-term medical volunteer work [1-9]. Editorials such as these raise concern about the ability of short-term volunteers to provide safe and effective medical services in the setting of language and cultural barriers that impair clear communication between patients and healthcare providers. They also raise concerns about a lack of follow-up care for patients who receive treatment from groups with a short-term presence. They raise ethical concerns about people without formal medical training participating in these groups, or medical professionals practicing beyond the scope of their expertise and practice at home, in a setting where they are not held accountable for the consequences of medical interventions made.
In addition to basic questions pertaining to patient safety, these editorials raise important questions about the impact of short-term medical missions on the larger medical systems in the countries they visit. For example, it is suggested that short-term medical groups that are not integrated with local medical systems do not understand local medical needs, and consequently, their efforts will be misguided.
Furthermore, there is suggestion that groups providing free medical care in other countries undermine the livelihood of medical providers who depend on payment from patients in those countries. The literature in medical anthropology is filled with examples of unintended consequences of medical programs that pay insufficient attention to local conditions and culture and, perhaps more importantly, fail to consider the potentially incompatible and harmful cultural assumptions and values embedded in those programs [10,11].
With countless groups from wealthy countries participating in shortterm medical volunteer work abroad, it is critical that we evaluate the safety and effectiveness of these interventions for patients, as well as the larger implications and consequences of such work on the development of medical systems and the health of communities where this work takes place. The editorials summarized above were written by medical professionals from wealthy countries with an interest in global health, and these writings serve as an important starting point in this discussion. Even more important, however, are the opinions and perspectives of those who live and work in the countries where this work takes place, and thus far, their voices have not been heard.
…Short-term medical volunteer work may be seen as one extension of those interests in the post colonial era. As such, short-term medical volunteers often bring with them, albeit unconsciously, attitudes that foster dependence and lack respect for local practitioners and local knowledge and practices related to health. Understanding how short-term medical volunteer work is perceived by those living and working in receiving communities is a critical first step in designing and implementing healthcare programs that provide needed healthcare services to supplement and complement local healthcare systems without undermining their efforts. Specifically, we sought to explore the perceived utility and perceived impact (positive and negative) of short-term medical volunteer work in Guatemala from the perspective of healthcare providers and health authorities in Guatemala. Because of the short time available for the research, this study focuses on the perceptions of these individuals and not on the impact of short-term volunteer programs. Its purpose is to identify and describe the range of perceived issues surrounding short-term medical volunteer work as a basis for future indepth studies.
…Our study, although small in scope, is one of the first to systematically and critically examine the effects of shortterm medical volunteer work. All major thematic areas in our results underline the challenges of outside groups working as equal partners. Is it paternalism or cooperation? Is it charity or aid? Is it experimentation or quality care? Have all stakeholders been properly identified? Let us say that a recipient community has been appropriately consulted and involved to develop the most suitable intervention with strong community ownership. Omitting other healthcare providers, organizations, and the Ministry of Health may nevertheless jeopardize the long-term success and sustainability of any effort. The very real power and wealth differential between short-term medical groups and their host communities make trust, understanding, and true partnership difficult.
…According to our results, recipient communities may perceive very tangible benefits from short-term volunteer groups: Free or discounted care, improved access to healthcare overall, access to highly-trained specialists, and access to procedures not always possible within the local infrastructure. Local providers enjoy exchanging experiences and knowledge with foreign visitors, and appreciate the influx of supplies that accompany volunteer groups.
White Coat = Authority
On the negative side, it appears some of the least sophisticated groups offer services or treatment that are seen to be at best duplicative, and at worst, harmful. For example, though some drugs may remain effective 1–2 years past their expiration date, the perception of harm may arise from using drugs that are no longer considered safe, legal, or effective in the US. Similarly, a surgical group not planning for appropriate local follow-up could also be seen as acting recklessly and creating the potential for harm. Such issues may be easily solved with proper planning and supplies. On the other hand, many situations described by our respondents do not present the opportunity for an easy fix. Well-intentioned, well-prepared groups provide services that may help many but may harm others though unforeseen externalities. For example, free care from outsiders improves access in the short-run, but may undermine local healthcare providers, and in the long-run may reduce access: The government might close public clinics with patient volumes that are dropping, and private physicians might leave for areas without competitors providing free care. This could only further increase the dependence on external assistance.
…Finally, it is our hope that this paper will stimulate studies into the economic, political, and health outcomes of short-term volunteer programs to critically assess their quality and effectiveness. What is the effect of the concentration of such services on the government investment in healthcare infrastructure and services in those areas? Do free or very low cost services provided by short-term volunteers truly draw patients away from private practitioners or state services? Are outcomes for procedures (e.g., cataract removal) or conditions (e.g., diabetes) different when care is provided by the regular healthcare system versus by short-term medical volunteers?
The above article brings up so many good points that have only begun to be addressed in a systemic way over the past few years. As recently as March 2011, a narrative article was published in Health Affairs which succinctly illustrates the challenges of participating in (much less creating and operating) a short-term medical volunteer program. Dr. Teeb Al-Samarrai, an MD with a strong interest in international health and development, wrote this article as a 2nd year resident who traveled to Uganda with Yale’s medical study abroad program to work in a hospital in Mulago. Here are some key excerpts from Adrift In Africa: A US Medical Resident On An Elective Abroad. (2):
“Virtually on her own and unsupervised in a Ugandan hospital, a young doctor develops suggestions for improving overseas medical training.
…“This wasn’t part of my orientation,” I thought. I’d prepared to work alongside senior Ugandan physicians, not to become a senior physician at the country’s major hospital before the end of my first day. But I’d trained in a medical culture of multitasking efficiency and realized there was no time to waste.
So we began making the medical rounds on forty-some patients, in a hospital I did not know, in a country I’d just arrived in, and in a language in which all I could muster were, “Hello, how are you?” and “Thank you.” My hours of studying Luganda, the complexities of Uganda’s colonial history, and the subtleties of HIV care seemed irrelevant.
Patients’ “vital signs” were only occasionally measured or noted. The medicine ward contained no blood pressure cuffs or thermometers, unless an intern happened to have one in his pocket. The interns’ responsibilities were dizzying, and their knowledge base varied. The economic and technological limitations of the medical care they could deliver verged on paralyzing.
…Inside, I was numbed by the realization that Mulago wasn’t an isolated rural clinic in the middle of nowhere: It was the premier referral hospital in a crowded metropolis in a country heralded as an HIV/AIDS success story. If this was success, I wondered, what did failure look like? My mind whirred, trying to calculate the incalculable other Mulagos, the smaller Mulagos throughout Africa, in more remote regions and poorer countries. It continued to whir as I tried to count the uncounted, the patients who never made it through Mulago’s doors, who never made it to any hospital at all.
Before the end of my third week at the hospital, I asked to work on an infectious disease ward. After all, that was the work I’d come for. I was told that it was still exam time at Mulago, and there’d still be no one to supervise me. I insisted. Although no expectations were laid out for me, I tried to set realistic ones for myself. Feeling more comfortable and familiar with Mulago, I began on the men’s infectious disease ward. Each day the ward intern and I did rounds on nearly sixty patients. I let him lead the way, both of us having growing confidence in what I knew and had to offer.
Interns from adjacent wards began to wander over, asking questions, wanting to present challenging cases. I didn’t always know the answers. But I taught the importance of performing a careful exam, listening to a patient’s medical history and personal story, and then creating a differential diagnosis (weighing the probability of one disease versus other diseases) while remaining willing to reassess it. Each day I was humbled by the dedication of the interns I worked with, who were eager to learn as much as possible. I was also humbled by the patients we treated and by those whom we could not treat, and by the caring and patience of their families. Day by day, we lived Mulago together
When I returned to my residency program in the United States, I asked faculty members what their expectations were of the role of visiting medical students and residents at Mulago. Although they were devoted to Mulago and to the experience of residents there, I didn’t get a clear answer.
Nor did I find clear guidance when I reviewed the medical education literature. There appears to be no standard for medical schools in the United States that outlines the necessary supervision for medical trainees—or delineates their roles, responsibilities, and expectations while they are working abroad. Moreover, many medical trainees go abroad with little more than a naïve desire to help and find themselves unprepared for the academic, emotional, and cultural challenges, not to mention the morally ambiguous situations, they might face.
Like many medical trainees, I went abroad to learn, to serve, and to be challenged. I and others want to be pushed out of our comfort zones and see the realities and necessities of medical care in resource-poor settings. We are drawn to this work because it helps us appreciate the dedication and skills of colleagues abroad as well as giving us a sobering perspective on health care disparities and priorities in countries that differ from our own. We can see diseases we’ve only read about, and we can hone diagnostic skills that atrophy in the technology-driven American health care system.
Even more, it is a form of service. We want to help. Ideally, we work with the guidance of seasoned physicians from our host country, home institution, or both.
Although I had ideas I could have tucked into the Mulago suggestion box, the most important recommendations I have now pertain to medical schools on this side of the Atlantic:
Suggestion:Determine the roles of US medical trainees and their responsibilities for patients during an international elective.
Suggestion:Determine who is responsible for supervising the trainees.
Suggestion:Define what kind of supervision the host institution is to provide for the trainees.
Suggestion:Determine how trainees’ home institutions can support host institutions in defining responsibilities for teaching and patient care.
As those of us in the United States consider our continuing role in international health and medical education, I hope we can do so realistically and creatively. Perhaps a portion of tuition fees at US medical schools could be devoted to helping host countries and institutions hire local physicians to deliver patient care and also to teach US trainees. Such a system would provide a sort of counterweight to the brain drain that both drives and is driven by the global hierarchy of medical care. Or, as my residency program now does, perhaps an adviser from the home institution could spend part of his or her time at the host institution, both to advise US students and to offer targeted instruction for students at the host institution.
Although my experience in Uganda was not what I expected it to be, it was incredibly valuable. I realize that many medical educators would maintain that this means “living Mulago” was a successful international elective. Well, yes and no. In the absence of guidance and supervision, I initially struggled to define my role and responsibilities, yet I ultimately gained a clinical and ethical foothold that gave me one of my most meaningful clinical and learning experiences. In the process, I acquired a lens that allowed me to glimpse some of the gaps in our approach to international medical education.
As medical schools continue the process of shaping and fine-tuning international medical curricula, I hope many of us will ask how much more students and residents could benefit clinically, culturally, and emotionally if they had more guidance and supervision. Separating the difficult from the impossible is something that can be accomplished. We need to continue to heighten our skills in distinguishing between the two when shaping global health programs. Surely, when future doctors benefit, their future patients—wherever they might be—will benefit, too.”
Al-Samarrai’s experience sounds disconcerting, as the mechanisms of “aid” and the failures of communication between host and guest institution were laid bare before her eyes during her time in Mulago. Significantly, she lands solidly in favor of such a medical service endeavor, especially when organized with a clearer set of responsibilities and expectations for the guest institution as well as greater investment by the guest institution in training members of the host institution.
The way Al-Samarrai describes this medical program reveals an imbalance of benefit. Providing this form of medical service gives the volunteer a significant learning experience, while the patients of the host institution may be receiving more limited care due to the limitations of not only the host institution but also the lack of efficient usage of guest institution expertise. Assumptions or ignorance of the hospital’s clinical reality, in combination with a lack of accountability on the part of the guest institution’s leadership, created a fragmented experience for the intern. These kinds of assumptions and lack of accountability leave the door open for abuse by interns who might have more self-interest than social responsibility. Luckily Al-Samarrai exhibited a true commitment to the spirit of her profession and took further steps to help bring more effective exchange of knowledge to the program in which she took part.
However, when left unstructured, this kind of medical aid project has the potential for reproducing the more imperialist leanings of some development projects which bring in foreign “experts” that consequently pack up and don’t leave any knowledge behind when they complete their volunteer time period. Or even worse, some medical aid projects bring much-needed medication to the area or begin to vaccinate parts of the population but run out of resources and leave the remaining population high and dry. Although the Ugandan medical endeavor is not overtly imperialistic in the way that some pharmaceutical-based “aid” projects have been, Al-Samarrai’s experience on the ground reaffirmed the heavy responsibility of the guest to create a clear exchange of services, in a well-defined and accountable way.
Another article outlines the concept of “voluntourism” as it is practiced in the allopathic medical community.
The excerpt below is taken from the article: Fly-By medical care: Conceptualizing the global and local social responsibilities of medical tourists and physician voluntourists (3). It provides further recommendations for the practice of culturally and socially aware medical volunteering.
The Association of American Medical Colleges’ (AAMC’s) offers four foundational ethical considerations prior to embarking on global health voluntourism: (1) ensuring high ethical and moral standards, (2) developing a social contract with the communities served, (3) subordinating self-interest to the interest of the communities served, and (4) ensure that core humanistic values (honesty and integrity, caring and compassion, altruism and empathy, respect for self and others) are at the forefront of all activities [23]. These ethical considerations point to a number of specific social responsibilities that physicians involved in voluntourism hold, such as ensuring that compassionate and respectful care is provided that meets the highest ethical and moral standards that the context allows for. What these guidelines lack are specific, concrete strategies for enacting ethical, socially responsible care. The 4Rs that were developed by Aboriginal leaders in Canada to guide researchers in working with their communities, which are summarized in Table 1, offer some suggestions for specific strategies [63].
Generally, socially responsible medical voluntourism is a collaborative process that considers the full participation of local communities, local healthcare workers, and local health authorities [54]. It complements principles of international solidarity and social capital within the context of civil society, where voluntourists act voluntarily and without seeking personal profit to share benefits. Physician volunteers are encouraged to develop a sense of professional and personal growth, and to examine critically what it means to be a socially responsible practitioner [93]. For example, many voluntourists seem to believe that being socially responsible means charity [60]. But charity can create dependency relationships whereas social responsibility aims at social justice, understood as developing sustainable relationships based on mutual respect. It involves working with and for communities to enable what they feel is best for them rather than using a paternalistic approach. Dickson and Dickson [60], identify a list of personal attributes that physicians need to develop as part of their professionalization and to act responsibly that include: a concern with global equity; a commitment to redressing injustices in healthcare; respect for diversity; openness to mutual learning; and embracing ethical values like human rights and social justice. The professionalization of physicians gives them norms by which their social responsibilities as voluntourists are increasingly clearly stated. It also gives physicians the information and expertise with which they may act on these norms.
The 4Rs of Ethically Sound Research -
Ethical, Principle, Strategy.
1. Respect: Valuing cultures’ and communities’ diverse knowledges regarding health matters and developing knowledge that contributes to communities’ and cultures’ health and wellbeing
2. Relevance: Ensuring that research (or practice) is relevant to the culture and community
3. Reciprocity: Incorporating a two-way process of knowledge exchange and learning, where all parties benefit from these opportunities and the development of relationships
4. Responsibility: Fostering empowerment through allowing for active participation and rigorous engagement by all parties.
These guidelines seem reasonable on paper. Any thorough international medical organization can meet the first two R’s, but it seems like the second two R’s pose the biggest challenge. Those two R’s also represent what is missing from health care in general in the U.S.- so how do we expect to be able to accomplish them abroad? Or is medical voluntourism an opportunity to hone these personal and organizational skills abroad and then bring them home to create a more just health care system in the U.S.? Please feel free to share your opinion, since this type of debate is currently raging and unresolved.
Two excellent talks regarding these issues:
TEDx Talk Rainier: Dr. Wendy Johnson – A New Paradigm for Global Health: SolidarityThrough her national and international health advocacy work, Johnson believes that the key to overcoming disease burdens in both developed and developing countries is to strengthen and rebuild public health care systems. And that is exactly what she is doing. As clinical faculty in University of Washington’s School of Public Health and Director of New Initiatives for Health Alliance International (HAI), Johnson develops projects to strengthen public primary health services and advocates for universal health care access in low-income countries.
TEDx Talk Rainier: Dr. Stephen BezruchkaDr. Stephen Bezruchka seeks to expose why health disparities among nations around the globe are at record highs and empowers people to address the socioeconomic inequities that have most impact on the health of populations. He is especially interested in how people in the USA don’t live very long or healthy lives. Bezruchka’s work takes him from teaching at the University of Washington’s Department of Global Health to remote regions of Nepal, where he wrote the first guidebook to travel there, set up a community health project, organized a rural hospital for the Generalist Doctor Training Program, worked with Nepali doctors to improve surgical services in district hospitals, and now consults on population health issues.
Bezruchka worked in clinical medicine for 35 years. He received the UW School of Public Health’s 2002 Outstanding Teacher Award and the 2008 Faculty Community Service Award. He founded the Population Health Forum to raise awareness of, promote dialogue about, and explore how political, economic and social inequalities interact to reduce the overall health status of our society.
To see some aspects of the debate regarding humanitarian aid and medical voluntourism, you can check out Nassim Assefi’s TED Talk page. The question below prompted an interesting discussion.
What’s the most effective model of global health aid/development, given interventions can have complex, unpredictable and longterm impacts?
A debate is raging between those who believe humanitarian aid is corrupt, ineffective, and harmful (eg Dambisa Moyos of the world) and those who believe it is the moral imperative of wealthier nations to help the poor (Bill Gates, Nick Kristof, Paul Farmer, etc). As an idealistic young doctor with a privileged life and education, I wanted to give back to the world, starting some 20 years ago when I joined my first NGO. Since then, I’ve seen many different models of global health with variable effectiveness–Doctors Without Borders approach of relieving suffering but not building infrastructure, more standard NGOs that combine the two, large UN agencies (eg UNICEF, WHO, UNFPA, ICRC), medical diplomacy (free exportation of Cuban health workers), social entrepreneurship (eg Acumen Fund), missionaries, Gates Foundation/Global Fund/World Bank, international medical research posing as aid, etc. While objective successmetrics and monitoring and evaluation plans are now the standard part of most health interventions, what do we really know about the longterm, complex outcomes of our well-intentioned health interventions? Have we propped up an illegitimate government or strengthened a democratically-oriented one? Have we destroyed local economies or sustained them? Have we exacerbated brain drain or created jobs for internationals who want to return home? Weakened local infrastructure or strengthened it? Educated or misled? Oppressed the people we were supposed to help or empowered them? Please help me figure out the most effective way to use my medical and public health skills to improve health in a global context, and in doing so, help many others who are struggling with these issues. I would love to hear your experiences, perspectives, and ideas about how to do global health work right and how you might measure the complex, longterm impacts of what you propose. (Meanwhile, ironically, the US still lacks a decent, universal, and cost-effective health care system.)
The next post here will investigate how Traditional Chinese Medicine fits into this framework for socially responsible medical voluntourism.
Meanwhile, enjoy the excellent music of radical Portland folk-punk-hardcore band Adelitas! The lyrics for the song in English can be found at the end of the article.
References:
1. Green T, Green H, Scandlyn J & Kestler A. (2009 Feb) Perceptions of short-term medical volunteer work: a qualitative study in Guatemala. Globalization and Health. 5:4. Retrieved from: http://www.fresno.ucsf.edu/global_health/downloads/PerceptionsGuatemala.pdf
2. Teeb Al-Samarrai.(2011 March) Adrift In Africa: A US Medical Resident On An Elective Abroad. Health Affairs. (30)3:525-528
3. Snyder J, Dharamsi S & Crook V. 2011. Fly-By medical care: Conceptualizing the global and local social responsibilities of medical tourists and physician voluntourists. Globalization and Health. 7:6. Retrieved from: http://www.globalizationandhealth.com/content/pdf/1744-8603-7-6.pdf
Hay Que Luchar:
Get up, raise your voice- Can’t you see that so many silences wound us? Time goes by, there seems to be no solution. And when you lose hope, know that I understand you.
Wake up!
It’s not the time for remorse, bitter pasts. Let’s not let this suffering detain us. Our thoughts torment us, and knowing what to do, we end up paralyzed. And what if our hands had the power to break down the old walls, and nothing could stop us?
The future remains unwritten, in spite of the illusion of control- If we want anarchy, we have to fight for it – with militancy and love. It’s coming to end, this cruel empire. centuries of dementia, oppression, extermination. Let the storm rain down, drown this hell and we will know how to swim..
Organizing resistance with strategy and persistence- For freedom, for humanity never giving up. I know how easy it is to lose hope in this world of war and fear but come on we have one life nothing more- let’s fight for a better world. And you’ll see that our hands do have the power to make our dreams real, to build a new reality.
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