It started after one of those nice conversations you have with someone you’ll (probably) never see again. We both exchanged pleasantries sharing about our personal histories and goals for the future. After a brief discussion about malaria and the risk (or lack there of) of contracting malaria in Kitale, it happened.
This weekend is graduation weekend at the African Theological Seminary. This means many things: one of which is the board of directors (a bunch of retired – or soon to be – Americans) is in town for the week. Hectic, busy, and long begin to describe the week, but the week is also filled with fantastic shows and illusions aimed to make the board feel good about the work being done by those actually working in Kenya. In a word, the week is a circus.
One evening last week there was a dinner organized for the international board members to get to know the staff and faculty at ATS. After filling my plate with rice, chicken masala, chipati, and sukuma wiki (kale) I sat down next to a board member to chat. The sun had set and (I guess) the bugs had began to swarm because he suddenly said, “Boy, I hope I don’t get malaria out here”. I assured him that Kitale is actually too high in elevation (8,000 ft) for malaria mosquitoes to reproduce, so the only way one can come down with malaria in Kitale is if a malarial mosquito “commutes” from a lower elevation location in a vehicle.
I then slipped into my standard “impromptu” lecture about malaria: When people from the West hear about malaria we hear about it as this vicious killer, don’t get me wrong malaria kills, but the fact is for many Africans – who survive childhood – malaria is like the flu. Sure, many people die from the flu but many more people survive. The real tragedy of malaria is the loss of productivity it creates because Africans tend to contract malaria much more often than Americans contract the flu, AND (unlike the constantly evolving flu virus) malaria is entirely preventable.
I went on to explain that malaria is also over-diagnosed as a sickness in many parts of Africa. Whenever anybody starts to feel sick they get a malaria test and it (almost always) comes back positive. This is the unintended consequence of a health system that is completely consumer driven. Public expenditures in health are usually very low in African countries (see below for numbers on how low), so the need for health care is covered by the private sector. So, when a sick person goes to a medical testing lab, they ask for a malaria test, the private medical lab does when any good business does: gives the customer what they want. The test (invariably) comes back positive and the sick person takes malaria medication. Here’s the thing, once anyone takes malaria medication they will always test positive for malaria in the future because part of the medication is the actual malaria virus itself. I concluded saying this is the self-perpetuating problem countries with low public spending on health care experience.
This touched a nerve with the man I was sitting with (because apparently public action in health care is a hot button topic in the US) and caused the man pause for a moment, “hmm”, he said, “Let me refute what you’ve your statement about public spending on health”. From here he went into an impassioned rant about health care policy in the US, and how “he’d go as far as to say any public spending in health care – or any other area – does not work”. I sat next to him, sipping my tea, and nodded politely throughout his rant. (Remember 90% of the purpose for this week is to make the board feel good.)
His rant reminded me of a couple things. (1) Don’t take convictions about American politics into a discussion about African politics. It is a horse of a different color or apples and oranges. Yes, both American politics and African politics are messed up, but they are flawed in different ways. (2) Most people posses a huge misunderstanding of welfare and entitlements, the concept of dependency, and the impact of government spending in their own life. Somehow food stamps are bad but farm subsidies are good. Somehow we fail to see that the tax deductions we realize on our home mortgages are actually a larger government “handout” than the total government spending on public housing for the poor. It reminded me of this video created by University of California Berkley.
I decided to be civil and not refute his rant, as I believe issues of importance (like public expenditures on health) should not be discussed with impassioned opinions but rather with evidence and data.
It just so happens that I am currently reading Angus Deaton’s new book The Great Escape: Health, Wealth, and the Origins of Inequality which includes a chapter dissecting the question, “Why do people born in some countries live longer and healthier lives than people born on other countries?” Allow my summary of this chapter be by rebuttal to the board member’s rant.
“There are many countries where large fractions of children still die, and there are three dozen countries where more than 10 percent die before their fifth birthday. They are not dying of “new” diseases, like HIV/AIDS, or exotic tropical diseases for which there is no cure. They are dying from the same diseases that killed European children in the seventeenth and eighteenth centuries, intestinal and respiratory infections and malaria, most of which we have known how to treat for a long time. These children are dying from the accident of where they were born, and they would not be dying had they been born in Britain, Canada, France, or Japan.”
After World War II significant reductions in mortality rates (increases in life expectancy) were realized. “Countries like Jamaica, Malaysia, Mauritius, and Sri Lanka saw annual increases in life expectancy of more than one year or more for more than a decade.” These increases in life expectancy were “caused partly by the introduction to penicillin, partly by used of somewhat older sulfa drugs, and probably in large part by “vector control” (the chemical assault on disease-bearing pests, such as mosquitoes).
Medical and public health advances are not the entire story, however. Better education and higher incomes help too. In the late 1980s and into the 1990s the fraction of rural Indian girls enrolled in school rose from 43 to 62 percent. Educated women have fewer children and can devote more time and recourses to each of their children. Lower fertility is good for mothers too, reducing the health risks of pregnancy, and allowing women greater opportunities in their own lives. “Economic growth puts more money into the hands of families who are better able to feed their children, as well as into the hands of local and national governments, who are better able to make improvements in water supply, sanitation, and pest eradication.”
It is disputed how much effect each of these areas has on health and life expectancy. There is no reason to suppose, however, that the effects are balanced and static. Whatever takes the credit, it is clear that “less-developed countries” have experienced an increase in life expectancy and are closing the gap between rich countries. In 1950 the difference between life expectancy in Sub-Saharan Africa and Northern Europe was 31.0 years in 2010 the difference was (a still large) but decreased 26.5 years.
Still the question remains: Why should children die in poor countries when they would not die if they had been born in rich countries? While poverty is an obvious candidate, focusing on income as the main character of this story is incomplete at best. Indeed “there is little evidence that countries that grow more rapidly have had faster declines in infant or child mortality.”
It is important to understand what children who are born in poor countries generally die from, so that we can better understand how to deal with and prevent these deaths. One category of deaths include tuberculosis, malaria, diarrhea, and respiratory infections require better “pest control, better water, and better sanitation, all of which require collective action, organized by a central or local government. What might be called the physician-patient health-care system cannot do much about these problems.” Another category of deaths include childhood diseases, from prenatal and maternal conditions, and from hunger could all be prevented by better pre and postnatal care. “Giving a mother advice before and after birth of her child, having health facilities available to deal with emergencies and complications, and having clinics and nurses that monitor young children to check that their immunizations are up to date, to ensure that they are growing as they should, and to advise parents.” A better education system for mothers would help some, “but doctors, nurses, and clinics can help children and their mothers get through this risky time” of life.
The answer is rather clear: better health takes public spending on health (pest control, better water, and better sanitation) and a better physician-patient health-care system. The problem is it is impossible to meet these needs when the typical Sub-Saharan African country spends only $100 per person for health services.
For an example of the diversity of public spending on health throughout the world see the graph below. Zambia spends about $90 per person, Senegal $108, Nigeria $124, and Mozambique only $49. While Britain spends $3,470 and the United States spends $8,362.
We could get into the specifics about why the governments of poor countries spend so little money on the health of their citizens, as Deaton does in depth. But I’ve already written a lot and it is a bit technical and complex for a personal blog. If you must know the headlines, it has to deal with political corruption, distorted political incentives, behavioral inertia, and the relative nature of “good health”.
What is clear is that public spending on health is actually one of the most important factors for healthy citizens in a country. What is also clear from the graph above is that the US currently spends way way WAY too much of it’s public budget on the health of it’s citizens. It is spending money that is not producing healthier people, money that could be used in other desperately needed areas i.e. rebuilding and/or fixing aging infrastructure, expanding resources available to public school systems, or reducing/eliminating detrimental taxes (i.e. the payroll tax).
Update: This essay in no ways makes any judgement or evaluation on the Affordable Care Act. This should go without saying as the ACA is not mentioned once, until now. The purpose of this essay was only to refute the heretical notion that government spending, especially in health, does not work.