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Generation games: Great strides have been made against disease and poverty

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IF YOU look beyond the rich West, most of which has been in a funk ever since the financial crisis of 2007-08, the world has had an amazing run. Fully 6m fewer children under the age of five died in 2016 than in 1990. Never before have so many people been free of grinding poverty and ill health. Never have women been so unlikely to die as a result of giving birth, or to lose a baby to illness.

But the possibility that after this long winning streak humanity could be about to trip and fall is preoccupying Bill and Melinda Gates, a pair of self-described “impatient optimists” who run a foundation dedicated to solving the world’s problems. A report from the foundation published on September 13th suggests that progress on several fronts may be starting to falter.

For a variety of reasons, from demography to American and European politics, Mr Gates fears that campaigns to eradicate extreme poverty, HIV and malaria are going awry. He also believes that the rich world has not noticed. The Bill and Melinda Gates Foundation has hitherto been characterised by confidence, especially about the potential for technological innovation to solve the world’s knottiest problems. So the change of mood is significant. Peter Piot, director of the London School of Hygiene and Tropical Medicine, describes the report as “a wake-up call”.

Demography is one of the biggest reasons for gloom. Few countries in a terrible mess have a low birth rate (Libya and Venezuela are among the rare exceptions). In general, the poorest parts of the world, with the worst health, have the highest birth rates. In recent decades an enormous fertility gap has opened between these benighted places and everywhere else. It is caused not by women in poor countries having more children but by women everywhere else having many fewer.

In 1950-55 Africa’s most populous country, Nigeria, had a fertility rate of 6.4 (meaning that a woman could expect to have that many children if she survived through her childbearing years). That was much higher than in Europe or North America, but similar to the biggest countries in Asia and Latin America. In the early 1950s China’s fertility rate was 6.0. India’s was 5.9 and Brazil’s was 6.1. Six decades later a chasm had opened up. In 2010-15 Nigeria’s fertility rate was estimated to be 5.7, whereas Brazil, China and India all had rates below 2.5.

High birth rates put a big strain on countries. They lead to high dependency ratios, meaning that a relatively small adult population must support lots of children. In mostly agricultural societies, farmers must scratch livings from smaller plots on ever less fertile soils. High birth rates also have an arithmetical effect on global averages measuring development. When lots of children are born in countries that are largely poor and unhealthy, and few in better-off places, the world taken as a whole becomes poorer and sicker. “Just to tread water takes increasing effort,” says Chris Murray, the director of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, which produced most of the forecasts for the Gates report.

Date with destiny

Over the next few decades the fertility gap between Africa and the rest of the world is expected to narrow, but only excruciatingly slowly. If UN projections are right it will take 40 years, from the early 2010s to the early 2050s, for the fertility rate in sub-Saharan Africa to fall from the current level of five to below three. The same drop occurred over 25 years in Latin America and the Caribbean, and just 20 years in Asia, beginning in the early 1970s. The population of sub-Saharan Africa, which stands at about 1bn, is expected to reach 2bn in 2046 and 3bn in 2071.

This demographic divergence is a big reason to fear that poverty will stick around. Today 9% of the world’s people are believed to live in extreme poverty—defined as consuming less than $1.90 a day at 2011 purchasing-power parity. About half of those people are under 18. This represents remarkable progress: in 1990 about 35% of all people were thought to be extremely poor by the same yardstick. But progress will probably be much slower from now on.

In the past quarter of a century, poverty has fallen greatly in Asia and Latin America. In 1990 two-thirds of Chinese people lived in extreme poverty. At the most recent estimate, which relies on data from 2013, just 2% did. China is responsible for two-thirds of the overall drop in deep poverty between those years. India, Indonesia and Vietnam are also seeing it gradually disappear. In short, says Homi Kharas of the Brookings Institution, a think-tank in Washington, DC, whose forecasts the Gates Foundation uses, the “big pools of Asian poverty” are drying up.

Sub-Saharan Africa is sadly quite different. Although the share of Africans living in deep poverty is falling, it is not falling quickly enough to outweigh rapid population growth. The number of paupers in sub-Saharan Africa is holding steady at roughly 415m. Half of the world’s poor people are now thought to be African (though statistics are patchy for some very poor, dysfunctional countries, such as the Democratic Republic of Congo).

The region’s poverty is particularly intractable. This is largely because so many of its paupers live well below the threshold of extreme poverty, meaning it is harder to pull them over that level. It is also unpredictable. A terrible ruler, a war or a dismal harvest could send poverty rates shooting up. The growing weight of African paupers in the global total makes forecasting tougher. But overall, Mr Kharas expects the share of the world’s population living in extreme poverty to fall to 6% around the mid-2020s, and to remain at that level in 2030.

Ancient evils

Infectious diseases add to the reasons for concern. Controlling them often requires increasing effort and rising levels of spending just to stand still. But for many illnesses that afflict the world’s poorest people, future funding is uncertain. That includes HIV, malaria and the 20 ailments collectively referred to as “neglected tropical diseases” (NTDs), such as lymphatic filariasis, river blindness and sleeping sickness.

The example of HIV is cautionary, says Mr Gates. He fears that Americans and Europeans, lulled by plummeting infection rates in their own countries, and treatment protocols that can keep the disease at bay for decades, think the global battle against HIV is largely won. The term “AIDS-free generation” is being bandied about. But in some poor countries there is a serious risk that infection rates will start to rise.

Tackling HIV requires co-ordinated action on several fronts. The number of people being infected needs to be brought down, for example by promoting behavioural changes such as using condoms. Those already infected must be kept alive and healthy, which requires systems capable of delivering anti-retroviral drugs and other care. As time goes on, rising survival rates mean that the number of people with HIV in the population keeps growing. Treating all of them becomes more difficult and expensive—and poor countries where many people are infected, as in much of Africa, struggle most. If funding cannot keep pace, more will receive inadequate treatment. The virus will multiply in their bodies. They will become more infectious and spread the disease further. And they will die young.

The coming years will see the largest youth cohorts in Africa’s history. By 2030 the continent will be home to more than 280m 15- to 24-year-olds. And more young people means more sex, says Dr Piot. “If we continue to do what we are doing now—which is already a considerable effort—that is not going to be good enough.”

Malaria, too, has been beaten back in the past 15 years, but could stage a resurgence. A vaccine is already in use in several countries, but its efficacy is limited and it is not yet clear how much use it will be in the poorest countries. Drug companies and research foundations are working to develop better ones, but success is some way off. In the meantime, drug-resistant strains could evolve and spread. Without continuing research into new insecticides to use with bednets, says Mr Gates, deaths from malaria could rise again, as high as 1m a year.

He also worries that a “mood of retrenchment” means that Western countries are losing interest in the poorest parts of the world. At the same time, many developing countries are failing to spend enough of their own money on health care. A new paper in The Lancet, a medical journal, finds that 32 countries in sub-Saharan Africa spend less than 3% of GDP on health. Experts regard 5% as the minimum required to cover the basics.

International aid remains essential. Britain’s government has stuck to a pledge made in 2013 to meet a UN target of spending 0.7% of GDP on aid (Britain and Germany are the only large donor countries to have reached that level). But this target is controversial, not least within the governing Conservative Party. It might not survive a financial pinch caused by Britain’s exit from the European Union.

Hunkering down

More broadly, in Britain and elsewhere in Europe, the political case for aid is changing. Governments are presenting it to voters less as a way to help the world’s poorest people and more as a way to discourage them from trying to migrate to Europe. The European Union has allocated funds to the governments of several countries, including Niger and Turkey, in the hope that they will clamp down on people-smuggling.

And rich countries have taken to including the cost of dealing with the refugees who fetch up on their shores as part of their foreign-aid spending. Between 2014 and 2016 in-country spending on refugees by the 35 mostly-rich members of the OECD has risen from 5% of net aid to 11%. Such spending does little or nothing to help sorghum farmers in Mali or girls in rural Bangladesh.

Mighty oaks from little acorns grow

President Donald Trump has already slashed American funding for charities that provide, or even talk about, abortions in other countries. That will probably lead to more unwanted pregnancies (and more abortions) since many of those charities also provide family-planning services. Mr Trump’s proposed budget would slash foreign aid more generally. Since America is the world’s largest aid donor, that would have a big impact.

Cause and effect

Congress is likely to make amendments, but not to the extent that spending actually rises. This would be a change in direction. Under George W. Bush America led the global fight against HIV. Now, Mr Gates says, “the best case is flat funding to deal with a larger pool of people.” The foundation’s report includes projections of the impact of possible cuts to funding for HIV. A cut of 10%, it predicts, could cost 5.6m lives between now and 2030.

Is all the pessimism warranted? On some indicators, notably maternal mortality, the Gates report is reasonably sanguine. And better policies in developing countries could do much to improve the lot of their poorest citizens, even without spending more. India, for example, which Mr Kharas estimates still has 92m people in extreme poverty, could stop frittering money on fuel subsidies and other hand-outs that have mostly gone to the better-off. Sub-Saharan Africa could also fare a little better than expected. Though many of the region’s governments are weak and corrupt, at least most are stable these days.

The most hopeful development would be an unexpected decline in birth rates in sub-Saharan Africa. Demographers have been caught out before. In 1978, for example, the UN forecast a fertility rate for Vietnam of 4.4 in 1995-2000. The rate turned out to be just 2.2. Swift declines in the Middle East also came as a surprise.

The persistence of very high fertility in the region is something of a puzzle. Some researchers posit cultural explanations. Perhaps the boost to a man’s status from having many children is greater than elsewhere, or perhaps communal land-holdings mean that large families continue to be economically beneficial. More optimistic, since it suggests better policies could turn things around, is the theory that poor access to modern contraceptives is the main problem.

Look at Bangladesh and Iran, says John Bongaarts of the Population Council, in New York. Bangladesh promoted family planning by mobilising village women to preach the virtues of contraception. In the 1980s Iran lurched from pro-natalist policies to promoting family planning. In both countries, the birth rate plunged. Few African countries have done the same (the big exceptions are two highly authoritarian states, Ethiopia and Rwanda, and one well-run democracy, Botswana). “It’s really very frustrating,” says Mr Bongaarts.

Sub-Saharan Africa may muddle its way to a lower birth rate faster than the forecasters estimate, even without help from governments. The region’s cities are growing at a terrific clip of about 4% a year. This growth is often unplanned and messy, and the cities are seldom terribly productive. But urban living is likely to suppress birth rates, all the same. Whereas farmers can put even young children to work pulling weeds and minding goats, city-dwellers tend to find that their offspring add little to household output and, moreover, require expensive schooling. As a result, they seek to have fewer children.

Another hope for a better future is that medical progress will be faster than expected. Optimists put their faith in new drugs, better delivery systems and technologies as yet unknown: there is even the prospect of a vaccine for HIV, though certainly at least five years away.

Yet it would be unwise to rely on such breakthroughs, or indeed to imagine that the influence of medical developments on disease is always benign. Jeremy Farrar of the Wellcome Trust, a medical-research charity, warns that untreatable strains of HIV may emerge. Most pathogens eventually develop resistance to the drugs used to treat them. If drug-resistant strains become common, says Dr Farrar, “imagine controlling a second peak of HIV.”

The real value of the predictions in the Gates report is less that they give an accurate picture of the world in 2030, than that they provide estimates of what is at stake. Between its optimistic and pessimistic scenarios are the lives and wellbeing of millions of people. And even in the best cases, some countries will make slow progress. In 2030 the world is highly likely to have at least 490m poor people, according to the Brookings Institution. The forecasts show where there is the greatest potential to save lives and make them better. Between now and 2030, the difference between the best- and the worst-case scenarios in the deaths of under-fives represents about 7.8m lives, according to the IHME. For maternal deaths the difference is 377,000.

The report also highlights the biggest risks to progress—namely, the control of infectious diseases. If HIV or malaria comes roaring back, the impact will be felt very quickly. Worryingly, the greater the progress against a disease, the harder it is to motivate people and governments to keep going. An anti-malaria campaign in the 1950s and 1960s is instructive. After early success donors became complacent and the disease rebounded. One of the report’s most important messages, says Dr Farrar, is that “we have choices to make”.

Peak progress

Belief in the efficacy of aid, which reached a high point during the “Make Poverty History” campaign in 2005, has been hard to reignite after the financial crisis. Rich countries and their citizens are increasingly looking inwards. They seem pessimistic about their own prospects and less inclined to devote much thought and effort to those of others. Yet the past 15 years’ progress was built not only on investment, but on optimism, both in poor countries and rich ones. This generation has gained greatly from the generosity and resolve of the previous one. It remains to be seen whether the next one will be as fortunate.

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Julio Marchi ©

Publisher / Editor at BS News & Media Services
A free thinker, not labelled as anything, not associated with any party, not part of any group or engaged with any religion... A simple guy tired of the nowadays bullshit who decided to promote more serious debates about what is really happening hoping to bring back intelligence to the superficial and shallow news & headlines that unfortunately took over the existing media scene.
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