sexta-feira, 25 de março de 2011

ANTI-MALARIA BED NETS V F-35s


Publicado na The Economist.


Foreign aid

Anti-malaria bed nets v F-35s

Mar 25th 2011, 16:41 by M.S.
WHEN you argue for humanitarian military intervention, my colleaguerightly says, you should be able to show how your military intervention serves humanitarian goals. In the case of the decision to intervene in Libya, though, I think this low bar is pretty easy to clear. When you have a column of armoured forces loyal to a ruthless dictator advancing on a city full of weakly-armed rebels (initially non-violent protestors who took up arms in self-defence) upon whom he has openly promised to wreak bloody vengeance, you pretty much have the paradigmatic case for military intervention. We know how that picture ends; in Srebrenica in 1992 it ended with the bodies of 7,000 able-bodied males in unmarked graves, in Hama in 1982 it ended with 20,000 civilian dead in flattened apartment blocks, in Basra in 1991 it ended in mass graves and in the dungeons of Abu Ghraib, and so forth. It's true, as my colleague says, that people are clumsy with counterfactual scenarios, and have a patriotic wish to see their state as a force for good. But I don't think that these are the main reasons why we think things would have been worse if we hadn't intervened in Libya. At least for that initial intervention, I think you'd have to make some heroically naive assumptions to believe that things wouldn't have been worse once Mr Qaddafi retook Benghazi.
My colleague's chief concern, however, is why we seem to be so often faced with calls for military humanitarian interventions, rather than peaceful ones.
If our foreign policy aims to prevent suffering and death with finite resources, it makes sense to ask whether this war makes sense on those grounds. I grasp the tiresome point that the choice on the table was not a choice between taking out Libya's air defences and buying bed nets. The choice was between taking out Libya's air defences or not. But the question nagging some of us is why this was the choice on the table. Why didthis come up as a matter requiring urgent attention and immediate decision? Why is it that the choice to express our humanitarian benevolence through the use of missiles and jets gets on the table—to the top of the agenda, even—again and again, but the choice to express it less truculently so rarely does? If our humanitarian values really set the agenda, how likely is it that the prospect of urgent military intervention would come up so often?
Let me answer this in a roundabout way. First of all, I don't share my colleague's sense that it's tiresome to insist that the choice in Libya was not between bombing Muammar Qaddafi's tanks or providing more anti-malarial bed nets in Malawi, but between bombing Muammar Qaddafi's tanks or not bombing them. At the least, I think there is a standoff in tiresomeness between making this point, and making the familiar anti-malarial bed-net argument to which it responds.
In fact, the existence of high returns to investment on anti-malarial health campaigns in the developing world has become something of a catch-all argument against any other form of government intervention in recent years; most notably, it figures prominently inBjorn Lomborg's arguments against spending on reducing carbon emissions. And yet somehow we don't seem to be increasing the amount we spend to fight malaria, even as we are increasingly regaled with arguments that spending on things besides fighting malaria is foolish and wasteful, because we could save so many more lives by spending more on fighting malaria. Indeed, the 2011 budget submitted by the House slashes the State Department's budget for aid to fight malaria (and AIDS, and tuberculosis) in the developing world by billions of dollars, while leaving the budget for bombing Libya (and everything else the Defence Department does) untouched.
Congress is slashing foreign aid to fight malaria in large part because the one category of government spending that the American public actually wants to slash, by a wide margin, is foreign aid. Meanwhile, the public opposes cuts to the defence budget (though they oppose cuts to education, Medicare and domestic anti-poverty programmes even more). So the fact that the political sphere is debating whether or not to bomb Muammar Qaddafi's tanks, rather than whether or not to raise spending on anti-malarial bed nets in Malawi, isn't really that surprising. But why does the public want to cut foreign aid, rather than defence? One reason is that for the past decade and more, both serious development experts like William Easterly and unserious politicians, mainly on the right, have been strenuously arguing that most foreign aid doesn't work. In fact, in Mr Easterly's case, one of the things he argued didn't work (in his excellent book " The White Man's Burden") was centrally planned efforts to distribute anti-malarial bed nets. He thought this was one of those things that would work better with a market solution: we should subsidise at most $8 of the cost of each $10 bed net, but let the rest of the distribution work itself out via market mechanisms.
Again, it's not surprising that the public doesn't want to spend more on foreign aid for anti-malarial bed nets, when people keep telling them such aid doesn't work. What makes the situation more piquante is that, as Jeffrey Sachs argued in a 2009 article in Scientific American, in the specific case of bed nets, the claim appears to be completely wrong. The reason anti-malarial bed nets hadn't been much of a success in Africa before 2005 or so was that donors and executing agencies hadn't spent enough money buying them, and hadn't yet figured out how to distribute them. With subsequent experience,
the case for mass free distribution of bed nets has proved to be stunningly powerful. On the basis of experience and key public health concepts, official global policy has now adopted mass free distribution of anti-malaria LLINs as the global policy... Evidence has long shown that Africa’s rural poor are so destitute that many are unable to pay even a tiny amount for lifesaving health interventions, even when the costs are subsidized. Not surprisingly, attempts to sell them subsidized LLINs during the years 2000 to 2005 fell badly short, even at prices as low as $2 to $3 per net... The World Health Organization adopted mass distribution as its basic standard in 2007. In a Global Malaria Action Plan, the international partnership on malaria control known as Roll Back Malaria set a goal to distribute around 300 million LLINs in Africa through free mass distribution during 2008-2010, in order to cover all sleeping sites in malaria-transmission regions. Already, as the result of mass distribution, the coverage with long-lasting insecticide treated bed nets has jumped from perhaps 10 million in 2004 to 170 million nets as of the end of 2008.
Recently the Poverty Action Lab at the Massachusetts Institute of Technology carried out a detailed experiment in Western Kenya that compared mass distribution with a partial-subsidy approach. The results: even a small charge for bed nets led to a tremendous drop in their adoption. Moreover, there was no greater wastage of the nets received for free than for the nets that were purchased at the discount price. The conclusion of the M.I.T. study was clear: “Free distribution is both more effective and more cost-effective than cost-sharing.”
Mr Easterly and Mr Sachs have a long-running and intense debate on this and other development issues. I usually agree with Mr Easterly more than Mr Sachs, but in the specific case of bed nets he's had to retreat; more recently he's been sensibly pointing out that even if free distribution works better, you have to figure out a reliable way of identifying organisations that will actually do the distribution for free (rather than selling them illicitly, failing to distribute, etc), and there's no obvious scalable way to do that. But this only raises a further problem for the "bomb Libya or fight malaria" paradigm: how can you even ask the question if spending more on anti-malaria campaigns may not have any effect, since it's about the quality of the agencies, not the amount of funding? If there's no fungible way to shift effort from bombing Libya to fighting malaria, how can there even be a trade-off here?
Still, let's stipulate that shifting spending from the government bombardment of Libya to government anti-malaria efforts in the developing world would work. Certainly, few public-health experts would dispute that many health problems can be most efficiently addressed by having the government undertake preventive measures and distribute them for free. But here's the thing: you will hear approximately no voices on the right-hand side of the political aisle making this case in the United States today. The strategic direction of conservative political thought over the past 30 to 50 years has been to minimise the consensus on the extent of public goods: to argue that there are almost no areas of the economy or society in which government has a constructive role to play,except for national defence, and a few other areas such as law enforcement. Certainlynot health.
I would suggest that if we're wondering why the American public devotes so much of its political attention to wars, and so little to anti-malarial bed nets, we might want to consider the role played by consistent efforts over the past 30 years to convince the public that government has almost no legitimate or positive role to play in society apart from a few narrow categories, including law enforcement and national defence, and not including health care. People who believe that virtually all social and economic endeavours, apart from defence and law enforcement, are best addressed by leaving them up to market forces and private industry will not naturally see much else for political discussion to focus on apart from military activity and law enforcement. To put it another way: if we don't think peaceful humanitarian interventions (like anti-malaria campaigns in Malawi) work, then, yes, military humanitarian interventions (like bombing Libya) are the best possible use of American resources towards humanitarian ends. If we do think government humanitarian programmes like anti-malaria campaigns in Malawi work, then I would expect to see a rather different attitude towards foreign aid and public health-care spending than I have seen in American politics these last few years.
To put things in one last way: it simply isn't true that we aren't faced with calls for peaceful humanitarian interventions as often as we are faced with calls for military ones. We are faced with calls for peaceful humanitarian interventions all the time. People are asking for more money for USAID. People are asking for more money for UN peacekeepers. People are asking for more money for the United States Institute for Peace. They're asking for more money for the Global Fund to Fight AIDS, Tuberculosis and Malaria. If you want America, collectively, to be doing more of this sort of thing and less of the bombing sort of thing, then what you need to do is to argue that those sorts of activities are central missions of the United States government, because the most powerful political forces in America over the past couple of decades have been arguing that they aren't, and that's why we're not doing more of them.
(Photo credit: AFP)
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