Excerpt: "The End of Poverty" by Dr. Jeffrey Sachs

Excerpted from THE END OF POVERTY by Jeffrey D. Sachs. Reprinted by arrangement with The Penguin Press, a member of Penguin Group (USA), Inc. Copyright © Jeffery D. Sachs, 2005.

Africa's AIDS Cataclysm

From these lessons, it was but a small step to HIV/AIDS. The same three questions applied for AIDS as for malaria. What does the disease do to economic growth and poverty? What accounts for Africa's special circumstances? And what must be done? The answers are similar, but with one important difference. As of today, there is no solid explanation for why Africa's AIDS prevalence is at least an order of magnitude higher than anywhere else in the world.

The simplest answer, widely believed, is that in Africa there is more sexual activity outside of long-term stable relationships. The data, however, repeatedly cast doubt on that simple and widely-believed hypothesis. Perhaps the sexual networking is different in Africa (for example with more relationships between older men and younger women, or more concurrent relationships although not more lifetime partners). Perhaps HIV/AIDS is transmitted more easily in Africa because the population has other untreated ailments (malaria, other sexually transmitted diseases), or because men are much less frequently circumcised, or because condoms are less frequently used in casual sexual relations. Perhaps the viral subtypes (known as "clades") are different in Africa. The truth is that nobody is sure. The only thing that is certain is that HIV/AIDS is an unmitigated tragedy and a development disaster throughout Africa, especially in the hardest hit regions of Eastern and Southern Africa.

As for the economic costs of the disease, these certainly rival or exceed malaria in the disaster at hand. Africa is losing its teachers and doctors, its civil servants, and farmers, its mothers and fathers. There are already more than 10 million orphaned children. Business costs have soared, due to disarray from massive medical costs for workers, relentless absenteeism, and an avalanche of worker deaths. Foreign investors from outside of Africa are deterred from stepping into Africa's AIDS morass. And millions of households are battling with the illness of the head of household and the incredible toll in time and expense, to say nothing of emotional trauma on the rest of the family.

Once again, I looked at what was being done and what could be done. By the late 1990s, AIDS in the rich countries was being treated, with growing success, by anti-retroviral medicines given in three-drug combinations, so called highly active anti-retroviral therapy (HAART) or simply antiretroviral therapy (ARV). This therapy was changing the face of the disease in the rich countries. Individuals infected with HIV now saw hope. Others who thought they might be infected were willing to come forward for testing. The prospect of drug treatment, and therefore the readiness of more people to submit to voluntary counseling and testing, meant that prevention and treatment programs worked in a mutually supportive manner.

Certainly, I thought, the same must be happening in the low-income world. With all the worldwide attention on AIDS, and all the hand-wringing and speeches, surely the donor world was gearing up to help the impoverished world to fight this terrifying epidemic. But once again, my presumptions were wrong. Attaran and I went to work on the donor figures, and once again we were blown away by what we found. Could it really be right that the world was giving just $70 million to all of Africa to fight AIDS? Was this even conceivable? As we started circulating these data there was no statement of correction or complaint from the donors. These estimates were, stunningly, the right numbers, and soon afterward Attaran and I published them in one of Britain's leading medical journals, The Lancet.

Over and over again, I saw the difference between spin and reality in how the world community faced AIDS and malaria. At one point, for example, an IMF official published a letter in the Financial Times noting that health and education spending in poor countries with IMF programs was actually up 2.8 percent per year between 1985 and 1996. The fact is, however, that although the IMF was correct in a strictly technical sense, health spending was disastrously, indeed shockingly, low in African countries with IMF programs. In most cases, public health spending in 1996 was below $10, so the increase had been from almost nothing to almost nothing. I was initially amazed that the IMF would play such tricks with the public, but I came to realize that the Fund had no special feel for these numbers. The IMF management and staff know very little about public health, and have traditionally paid almost no attention to whether health spending in their client countries was $10 or $100 or $1,000 or more per person (as it was for the rich countries that dominate the Executive Board of the institution).

Around the same time, I made a speech noting that the World Bank had made no grants or loans during 1995-2000 for controlling AIDS in Africa. A bank spokesman attacked me vigorously. "You don't know what you're talking about. We had several program countries with AIDS programs." "That can't be, I've checked, and I did not find a single loan." Again, they were technically correct, in a way that utterly distorted the truth. There were probably a few dozen countries where AIDS was mentioned in a sentence or maybe a paragraph, in a loan for the health sector. The AIDS component was usually tiny, perhaps a few million dollars over several years. Up to the year 2000, these minimal efforts never even contemplated the use of antiretroviral drugs to treat AIDS.

In the late 1990s, in the wake of my public spats with the IMF over their mismanagement of the 1997-98 East Asian financial crisis, I went on the warpath with the international financial community over AIDS and malaria. I called for an end to the international community's gross negligence regarding the diseases ravaging Africa. I complained that the IMF and World Bank had been in Africa for decades, but had remained blind to the most basic realities there, and to the growing human and economic catastrophe.

At that point, I teamed up with President Olesegun Obesanjo of Nigeria to help prepare a major Africa-wide summit on malaria in Abuja, Nigeria in April, 2000. My colleagues, including several world-class malariologists at Harvard – Andy Spielman, Awash Teklehaimanot (visiting from WHO), and Anthony Kiszewski – and I wrote a key background report that demonstrated the massive burden of malaria on economic development in Africa and also stressed the opportunities at hand to control the disease.

At about this time, I received a call from Dr. Gro Harlem Brundtland, who had recently been appointed Director General of the World Health Organization. Brundtland was former Prime Minister of Norway and, without doubt, one of the world's most skilled political leaders. In the mid-1980s, she had chaired the famous Brundtland Commission that launched the concept of sustainable development. She said to me, "If you want to get someone's attention about the health crises in Africa, 'show them the money.' Help them to understand the economic costs of the disease pandemics, as well as the economics of disease control. Above all, propose practical solutions, based on a rigorous emphasis on economic costs and benefits."

Brundtland suggested that I chair a commission of macroeconomists and public health specialists to do just that. The WHO Commission on Macroeconomics and Health (CMH) was born. I chaired the Commission for two years, from the start of 2000 to the end of 2001. In December 2001, the CMH published its report, Investing in Health for Economic Development. This was the work of 18 commissioners, including Harold Varmus, Nobel laureate and former director of the National Institutes of Health; Supachai Panitchpakdi, who would go on to lead the World Trade Organization; Robert Fogel, the Nobel laureate economic historian at the University of Chicago; and Manmohan Singh, the former Finance Minister and future Prime Minister of India. In addition to this stellar Commission, we drew upon six task forces that included more than 100 specialists from around the world. The Commission and task forces had senior representation of the IMF, the World Bank, and several donor agencies.

The Commission gave me a wonderful opportunity to test my favorite hypothesis about collective rationality, which is that if you put people of strongly opposing views in a room together, and infuse their discussion with data, background studies, and unhurried time for debate, it is possible to bridge seemingly irreconcilable positions among the members of the group. I have come to call this process analytical deliberation. It works. The Commission was deeply divided at the start on who was "to blame" for Africa's roiling disease crisis: Africans for their mismanagement, the pharmaceutical industry for the greed, the rich world for their malign neglect. Did Africa need more aid, or just to use better those resources that it had at hand? Could anti-AIDS drug treatment be applied in Africa? On these and a dozen other issues, the first day of the two-year process was contentious, to say the least. On the last day, when the report was issued, we had reached a consensus that extended not only to the 18 commissioners and 100 or so experts in the working groups, but also to major representatives of the pharmaceutical industry and the NGO community. We worked diligently and assiduously to bring forward evidence and a consensus on three basic issues:

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.

My colleague Paul Farmer put those arguments to rest for me, and in some ways, for the world. A professor of medicine at Harvard, and a saint of global health, Paul had been running a clinic in the impoverished central plateau of Haiti since 1985. Using charitable contributions and drug donations from HIV-infected patients whose regimens had changed (leaving the patients with unneeded pills), Paul had begun introducing anti-AIDS drug treatment among his AIDS patients. He was getting marvelous clinical results. In January 2001, he invited my wife and me to his clinic to see the results. We went out to the villages to greet mothers and fathers who had been at death's door, but who were now standing tall with their children. Wherever we went, we were greeted with gracious hospitality by people who would have been dead but for a few pills per day.

Excerpted from THE END OF POVERTY by Jeffrey D. Sachs. Reprinted by arrangement with The Penguin Press, a member of Penguin Group (USA), Inc. Copyright © Jeffery D. Sachs, 2005.