Monday, August 16, 2010

Measurement of Success is the Measure of Our Failure

Out of the top ten killer diseases listed by AlertNet, most relate to a lack of something very basic:

Number one, lower respiratory infections are closely related to poor environmental and living conditions; 2, HIV/AIDS is related to many things, including healthcare, education, infrastructure, labor practices, legal issues, equality and others; 3, malaria is to a large extent related to environment and living conditions; 4, diarrhea is mostly related to poor water and sanitation; 5, TB, environment and living conditions.

It's not until you get to numbers 6 to 9, measles, whooping cough, tetanus and meningitis that you find diseases that are generally controlled with a vaccine. And controlling these diseases still requires adequate health systems, education and infrastructure. Number 10, syphilis, can also be controlled by good sexual healthcare, sex education and drugs.

But the point is that medical treatment is not health. Medical treatment is for people who are sick. In order to avoid numbers one to five, the majority of people need things like good housing and domestic facilities, water and sanitation, access to nutritious food, education and the protection of the law against discrimination, exploitation and inequality. If these basic needs are not met, medical treatment alone is unlikely to be of any use. These top ten killers kill millions of people because of the absence of things other than medical treatment and supplying endless amounts of medicine will not prevent illness and death.

The AlertNet article is perverse in that it doesn't mention that the biggest killer, lower respiratory infections, are spread by poor living conditions and that, therefore, deaths could be significantly reduced by concentrating on improving these conditions. One of the Millennium Development Goals includes reduction in child mortality as an indicator of progress. But that doesn't necessarily translate into improving living conditions. Children are especially susceptible to respiratory infections and much of the mortality from these causes occurs in children and infants. But providing lots of treatment is not a substitute for better conditions.

Similar remarks apply to malaria. It can be better controlled if people live in decent housing. When they live in villages, towns and cities, especially, the environment also needs to be such that malaria carrying mosquitoes can be controlled. But a large percentage of people live in semi-permanent housing that doesn't protect them from mosquitoes and other threats. Mosquito nets are good if people have enough space and enough beds to make them effective, yet many live in cramped conditions where mosquito nets are less effective. Technical solutions need the right conditions and have sometimes proven to be a waste of money.

One often hears calls for vaccines against diarrheal diseases and big donors are especially fond of such vaccines.  But what these big funders don't seem to want to ask is why are people drinking water contaminated with their own feces? These vaccines may have some impact at first, but if people don't have access to clean water and good sanitation, they will continue to be infected with other water borne diseases. Is it even logical to give some medicine to people who then continue to drink contaminated water? Vaccines may be a good supplement to eradicating some of the big killer diseases but without ensuring safe water and sanitation, they will have little effect. The same applies to pneumonia vaccines.

Providing people with decent living conditions, water and sanitation and the like are expensive. But billions of dollars are spent on vaccines, much of the money going to rich and powerful multinationals. There isn't a lack of money, just a lack of equity. Most of the money is being spent on subsidizing the rich; pharmaceutical giants, agriculture and the like. It's true that most people in developing countries don't die for lack of food, and malnutrition doesn't usually kill people either. But these both leave people weaker, more susceptible to disease and more likely to die of preventable and treatable diseases.

Sometimes it appears that development misses the point: yes, people are poor, undereducated, unhealthy, isolated and otherwise deprived. But a handful of indicators is not a measurement of development. The aim of development is not to produce a few Olympic runners, jumpers and throwers and then claim some gold medals. The aim is that everyone can enjoy healthy and fulfilled lives. Achieving some goal such as immunizing all (or most, or 80%) of children against a couple of waterborne diseases is a failure if they still die from some other waterborne disease; it's a failure if they don't have access to clean water and good sanitation. Immunization, like much medication, can be a necessary condition to ensure health, but it is not sufficient.

Of course, development experts are not advocating that everyone be supplied with medication and ignoring other conditions. But the money is mainly going towards the technical solutions and not going towards supplying basic needs. In developing countries, many people spend more money on healthcare and health care products than they do on more basic things. And where they don't have the money to spend, a lot of development money is spent on these services and products. Basic needs are prior, in the sense that they must be supplied first. In highlighting how basic some of the top ten killer diseases are, AlertNet takes the first step towards refocusing attention. But it fails to say why so many people in developing countries are dying needlessly or what can be done about it.


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