First, is disease a cause of poverty, a result of poverty, or both? The Commission concluded that causation runs strongly in both directions. Poor health causes poverty and poverty contributes to poor health. Second, why do poor countries have a life expectancy several decades less than rich countries? Why, especially, is Africa's life expectancy, at forty-seven years in 2000, more than three decades less than the seventy-eight years of the rich countries? The commission identified eight areas that accounted for the vast proportion of the gap in disease burden: AIDS, malaria, TB, diarrheal disease, acute respiratory infection, vaccine-preventable disease, nutritional deficiencies, and unsafe childbirth.
Third, how much should the rich world help the poor world to invest in health? The Commission calculated that donor aid ought to rise from around $6 billion per year to $27 billion a year (by 2007). With the combined GNP of the donor countries equal to around $25 trillion dollars as of 2001, the Commission was advocating an investment of around one thousandth of rich-world income. The Commission showed, on the best epidemiological evidence, that such an investment could avert eight million deaths per year.
The report of the Commission on Macroeconomics and Health had quite a notable reception. Reports come and go. This one, I think it is fair to say, came and stayed. It made the important point that we, as a generation, can do something dramatic to improve our world. The report found a wide audience, in part, because it was based on a wide and surprising consensus. It was launched with the kind of pizzazz that it deserved, with Brundtland; U.K. Secretary of State for International Development Clare Short; Ray Gilmartin, the CEO of Merck; and Bono as enthusiastic supporters.
Around the same time that the commission began meeting, I started to push the idea of a "global fund" to fight AIDS and malaria. At the International AIDS Conference in Durban in July, 2000, I gave a speech calling for such a global fund, and was very gratified to receive a prolonged standing ovation in response. Word spread of the speech and the idea of a new global fund took hold. I met with UN Secretary-General Kofi Annan, whom I consider the world's finest statesman, to discuss the practicalities and design of such a fund. He was very interested and asked me to work closely with his staff in the coming months to refine the concept.
One more piece of the puzzle was needed. As of early 2001, the donor world still shunned the idea of using anti-AIDS drugs in low-income countries to save the lives of people with late-stage AIDS disease. The donor world viewed anti-AIDS drugs as hugely expensive and technically impractical – in short, not "cost-effective." Getting global financing for them in Africa was still a huge uphill struggle. The most common claim was that anti-AIDS treatment wouldn't work anyway. Impoverished and illiterate patients would not be able to comply with complicated drug regimens.