Monday, April 26, 2010

Philanthropic Tokenism

Apparently Zanzibar succeeded in eradicating malaria in the 1970s, but it returned. Now they are about to eradicate it again, or at least, rates are far lower than they have been for a long time. However, there seems little chance that they will succeed in keeping malaria down for good.

Zanzibar, like many places in Africa, has problems with garbage disposal, sewage disposal, water, hygiene, infrastructure, especially roads and electricity, education, housing, poverty, health and many other things. These are the conditions in which a disease like malaria thrives. It is fairly certain that unless Zanzibar tackles these problems, malaria and other deadly (though preventable and curable) diseases will continue to be endemic.

The world was told that polio had been all but eradicated in the last few years and in a short time there would be no further cases. But polio has returned, partly because of a boycott on vaccinations in Nigeria due to rumours about their safety. As a result, there is talk of changing the polio eradication campaign from its present 'vertical' strategy to a more 'horizontal' strategy.

A vertical approach takes one disease and aims to vaccinate everyone who may be infected and, if possible, treat those who are already infected. A horizontal approach aims to provide health services for everyone and sees all diseases as being in need of prevention and/or treatment.

Realization that vertical approaches are not working and that horizontal approaches don't carry the kudos of being able to eradicate a whole disease gave rise to talk about health system strengthening and even 'diagonal' approaches, that would combine the horizontal and the vertical. Unfortunately, much of this has remained just talk.

There is even talk of Bill Gates taking a less vertical approach to polio eradication or risk seeing hundreds of millions go to waste. But I find that hard to believe. I don't think Gates lacks understanding of why polio (and other diseases) elude single disease approaches that involve some kind of expensive, technical fix. All he has to ask himself is why people are being infected by a disease that is spread through human feces. To put it another way, why are people drinking contaminated water?

Gates is fond of talking about water and sanitation but most of his money goes into things like vaccines. Indeed, much of it goes into US institutions and US citizens working on vaccines. Very few broad-based water and sanitation programmes, aimed at preventing all water borne diseases, are being financed by Gates.

Gates can spend his money and fail to eradicate polio or cholera or malaria or any of the diseases that he wants to be associated with eradicating. But as long as the water is contaminated, all his programmes will fail. As for his ideas on how to make the polio programme more 'diagonal', all that's mentioned is "training for health workers on topics such as hygiene and sanitation". Hygiene and sanitation are not just things people need to know about, they are things people need access to. It's no use health workers telling people to wash their hands and dispose of their faecal waste properly when they don't have clean, running water and adequate sewage disposal systems.

Maybe Gates will get involved in genuine 'health system strengthening', but just paying a few professionals more to work in his funded institutions is not going to help. That has just increased the brain drain from indigenous health institutions and taken attention away from health in general to concentrate on his favourites. But it seems more likely that he will continue to do what he is doing and put even more money into spin. After all, he has his agenda and evidence from the field has never affected that.

Diseases are not trophies and global health is not a matter of having a wall covered in certificates for attempting to eradicate a small number, or even a large number. Health depends on other crucial rights, such as food food and food security, water and sanitation, adequate living conditions and good education. Without these, throwing money at a handful of diseases will have little impact. Maybe some disease will be wiped out, or as good as, but people will continue to die of other preventable and curable diseases. Gates should work for human rights, any human rights or even all human rights. Instead, he's just wasting his money on philanthropic tokenism.



Joyful said...

Thanks for elaborating on what Gates' funding does. I am not very familiar with what his foundation funds or why but it troubles me that there doesn't appear to be much Africa-centered research done by Africans for Africans. They need clean water and sanitation. Most of them know that and there are a lot of expensive (bore holes) and less expensive (filter straws) solutions but you probably know better than most foreigners that these are well beyond the financial means of those who need them.

Simon said...

Hi Joyful
It's sometimes hard to figure out what Gates does as his organization is good at spin. But you're right, it's not about what Africans want and not much research comes from or belongs to Africa. Therefore, not much of it relates to Africa, unless someone with money is interested in something here.

The issue of water and sanitation is one of the most vital for health, you're right, but it is difficult and even funded programmes tend to concentrate on technical fixes, especially ones we already know don't work and cause a lot of serious problems later.

As for cheaper solutions, I have heard about sand damns and seen water pans, these are perfectly feasible for anyone but the problem is getting the technology out to people. It is certainly appropriate and affordable but some people are reluctant.

Rainwater harvesting in general doesn't seem too popular, I don't quite understand why. But low or appropriate technologies are certainly not highly prized by Gates or others in development!

You mention filter straws and while I think they are great for emergencies, I'm not sure how much of a long term proposition they are. They are still too expensive for people to use them regularly here and probably always will be.

Development, especially big funded development, seems to see everything as a crisis or an emergency. But health is not an emergency, people don't just need something to tide them over till things are better. Things will never be better until long term, sustainable solutions are used.

And I hope there are some Africans working on these solutions because I don't think there are any foreigners doing so!

George said...

I have heard that Gates' health philanthropies largely (exclusively?) use substances and processes protected by US patent and licensing regimes and that in other areas he and his company work very hard at defending such patent and licensing regimes, which are, of course the source of his (Microsoft's) wealth.

Simon said...

Hi George, yes, there's a lot of truth in that. Most of his 'big ideas' involve intellectual property, which is, of course, how he became so rich.

He is chasing after vaccines, microbicides, GMOs and greater use of antiretroviral drugs (in a procedure called pre-exposure prophylaxis, which involves putting healthy people on the drugs 'to prevent them from becoming infected').

I don't think many of these intellectual properties will be owned by Africans, perhaps a token handful. Some GMOs have been developed here but they are probably just a kind of Trojan Horse, something MS is also very familiar with.

There are also a token few programmes that don't involve IP, but not too many.

The Alliance for a Green Revolution in Africa (AGRA) involves other patented or patentable technologies. AGRA doesn't rule out GMOs but that simply means they will wheel them in when the groundwork has been done.

The Rockefeller people that he partners with have similar views but I think, historically, they were more overtly eugenicist.

Joyful said...

I found this useful article that gives a good overview of the national state of water needs in Kenya and what is currently happening.

There is a reference in the article to all the rainwater that has been falling of late in Kenya. I agree with your assessment that filter straws will in no way meet the need for clean water for Kenyans. There are numerous disadvantages to it but it would likely work for tourists.

Since I started off my comments with a reference to Bill Gates, I was surprised to find this link on Philip Emeagwali, a scientist who is sometimes called the African Bill Gates.

Simon said...

Hi Joyful
Thanks for your comments and the link. The water situation is bad, partly because it is always ignored as problems build up then treated as an emergency once things become too bad. And big damns have never been the solution. More, smaller local and appropriate technologies would probably work better and be a lot cheaper.

Life straws are good for emergencies, where you have a lot of people with no access to clean water, such as when there's a flood. But people can't drink from life straws for the rest of their lives. You're right, huge amounts of water are falling and have been for most of the last four months. Very few people are harvesting it, nor do most people have any idea of how to.

The problems with water in Kenya underline the importance of resisting allowing huge tracts of land to be taken over to be planted with crops for rich countries, whether it is for food or biofuels. People here need to ensure their own water and food security before exporting it.

Thanks again