Press: Over the past few centuries, people have witnessed miracles in the fight against infectious diseases. The incidence and mortality of infectious diseases have dropped significantly, and global health conditions have improved. However, this has not generally brought about improvements in economic benefits and governance levels. On the contrary, unprecedented urbanization is impacting the limits of what the ecosystem can withstand. Thomas J. Boykey, director of the Global Health Program at the Council on Foreign Relations, wrote the book "Plagues and the Paradox of Development" in an attempt to explore this issue in depth.
With the authorization of the publisher, Interface Culture has selected chapters involving disease, immigration, and international aid to share with readers. The author hopes that through this book, readers can look at what is happening in the world from a different perspective and then make a difference.
The next 20 years in low-income countries may be more violent than the last 20 years
In recent decades, low-income countries have been able to reduce the burden of infectious diseases with the help of medical inventions, the generosity and enthusiasm of international aid agencies, and the hard work and frugal innovation of local governments. In the past, many children were protected from avoidable death simply because they were born in a certain country. Today, this is becoming increasingly rare, which is a huge achievement. Still, infant and child mortality should fall to even lower levels. However, some countries still have not established the medical systems needed for this group of citizens who are about to reach adulthood, the urban infrastructure needed for settlement, and the robust labor-intensive economic form needed for employment. Therefore, while people celebrate those achievements, they should not ignore the challenges that will be highlighted in such countries.
The World Bank estimates that by 2050, the working-age (over 15 years old) population in developing countries will increase by 2.1 billion. If the employment rates in these countries remain at the 2015 level, only 1.2 billion people will be able to find jobs in their countries, and the remaining nearly 900 million people will have to keep looking for employment opportunities. Of these 900 million people, 333 million will come from sub-Saharan Africa, 283 million from South Asia, and 120 million from the Middle East and North Africa.
To date, climate change and extreme weather have had only a minor impact on international migration overall. The Internal Displacement Monitoring Center estimates that 19 million people were displaced by natural disasters in 2015. However, most of the population migration caused by this situation occurs within a country. This may change as sea levels rise, drought and desertification increase, and crop failures increase, causing more people to leave their homelands and emigrate.
Ultimately, young people, local activists and governments need to take responsibility for the long and hard work of pushing for the political and social reforms needed to adapt to demographic changes and the incremental progress made in reducing infectious diseases. However, aid agencies and international organizations should recognize that the dramatic changes currently facing low-income countries are occurring faster and with fewer resources than in the past. For example, these countries have not yet received the focus and support of international initiatives to reduce congestion in health and urban infrastructure, as well as to address non-communicable disease threats and adult employment needs.
However, people should be more aware that although the changes currently taking place in low-income countries have also occurred in high-income countries in history, the results were not satisfactory and were often accompanied by population emigration. The difference is that during the mass emigration of European populations in the 19th century, international migration was fortunately largely unrestricted. Immigration was even encouraged in both the sending and receiving countries at that time. After the end of World War II, many Western European countries and traditional immigration countries such as Australia, New Zealand, and Canada relaunched immigration promotion programs. Refugees from Eastern and Central Europe, including my parents, fled the ashes of revolution and war behind the Iron Curtain and were welcomed to a larger extent by the United States and other Western countries. This situation continued throughout the 1960s, but for low-income countries and their young people, the immigration environment of that time no longer exists.
With the outbreak of the oil crisis in the early 1970s and the economic decline of Western countries, governments around the world began to increase their efforts to restrict the flow of immigrants, refugees and undocumented workers. In 1976, a survey of member states by the United Nations Secretariat found that only 10 countries believed that their immigration rates were "too high." The 2011 survey showed this number had more than tripled to 33 countries. This shift in perception has been reflected in stricter immigration policies. Now, policy standards focus more on immigrants' skills and resources, and many countries have begun to adopt "points-based" visas, skilled personnel work visas, temporary business visas, student visas and investor visas, etc. In early 2018, U.S. President Donald Trump urged Congress to adopt a similar visa system, and in blunt and even allegedly vulgar language, called for more immigrants from developed countries, represented by Norway, and fewer immigrants from Haiti and poor African countries.
Undoubtedly, the racial and religious composition of the current immigrant population is a factor in this sentiment. For example, Western countries clearly need cheap labor to provide assistance to the growing number of elderly people in the country. As the baby boom generation ages and fertility rates decline, the number of people over 65 in high-income countries is surging. In the United States, this group is expected to reach 72 million people by 2030. The number of centenarians in high-income countries doubles every 10 years and is expected to reach 4 million by 2050. Millions of working but underemployed people in low-income countries could immigrate to Europe, Japan or the United States to provide care and emotional support to the elderly and frail, and to monitor their medication use. However, high-income countries have invested huge sums in the research and development of elderly care robots. Tyler Cowen has researched the role of automation in the global economy. I asked him about the implications of investing in automation, given that there is still a large pool of labor available around the world through immigration, and that these people can also fill the potential need for human interaction. His answer: "Voters will prefer robots."
Recent history confirms Ke Wen's intuition. In high-income countries, the public has expressed concerns about the inclusion of immigrants with different ethnic and religious beliefs and unfamiliar cultural and social customs, and politicians who have failed to respond to these concerns have paid the price. The results of the referendum on the UK's withdrawal from the European Union and the 2016 US presidential election surprised many observers, but they reflect a huge and still growing public unease about immigration. It is unclear to what extent these immigration restrictions and increasingly hostile attitudes will stem the flow of people. Legal immigration may be reduced, but restrictive policies and measures may also have unintended consequences, including encouraging irregular and illegal migration, delaying immigrant assimilation, and prompting permanent settlement for migrant workers who can no longer travel to their home countries. More thoughtful and implemented initiatives may have better results in the future. However, such efforts would put many Western countries in a paradoxical position: it was with Western funding that many countries achieved improvements in health standards, which to some extent brought about the natural result of population migration, but Western countries are now trying to restrict the flow of these immigrants.
All in all, the world is getting better, but the way it is changing is cause for concern. Over the past 20 years, the incidence of endemic infectious diseases and child mortality have declined significantly, but unlike what high-income countries have experienced in the past, there has not been an improvement in health care systems, improvements in responsive governance, and an increase in employment opportunities. Rapid population growth, unprecedented urbanization, and an increase in the proportion of young people are pushing the limits of what governments and ecosystems can endure, while exacerbating migration, instability, and the risk of global pandemics and chronic diseases. Many aid agencies have been slow to respond to the dangers of this limited success, and governments in many developed countries have adopted more restrictive trade and immigration policies, both of which have exacerbated these challenges.It is not difficult to imagine that the next 20 years in low-income countries may be more violent and conflict-prone than the last 20 years, which may lead to a rollback of some of the significant progress made in recent years.
We should be worried, but more importantly, we should act.
The role of international aid in the context of declining infectious diseases
In the face of demographic challenges, governments and local civil society, which have the greatest stakes in their countries' futures, will ultimately need to assume responsibility for setting national priorities and allocating scarce resources. For low-income countries, aid accounts for a smaller and declining share of total investment. In addition, various aid agencies are also external organizations. They cannot carry out institutional and social reforms that adapt to local needs through long-term and arduous efforts, nor can they promote the implementation of reform measures on behalf of low-income countries.
Past international aid initiatives have successfully provided food, cash, medicine and other technology to poor people in countries around the world, including countries with failed governments. Political and social reforms could help low-income countries seize the opportunities for improving health, but in reality, aid agencies and international organizations have failed. Aid agencies cannot manage basic health care systems in other countries, nor enforce sensible regulations on tobacco, land use or air pollution there. Aid agencies and philanthropic organizations have had little success in creating economic growth and employment opportunities in other countries, and there is a long way to go to build democracy, responsive governance and sustainable urban planning. The actions of bilateral aid agencies rely on the opinions of their domestic constituencies, and it is difficult for them to justify investing in infrastructure such as roads, bridges, sewage systems, and hospitals in recipient countries, because these facilities should ultimately be provided by local governments. It would be a profoundly conceited idea to believe that philanthropy and international aid can stem the social, political and economic forces that drive young people to seek a better life and emigrate.
However, this does not mean that aid officials, charities, policymakers and other readers cannot help low-income countries meet their daunting tasks. Progress will depend on mobilizing greater support to change the way international aid seeks to promote health and development in low-income countries.
The reduction of infectious diseases has partly led to changes in the overall environment. Stewart pointed out in a 1968 speech that humans need to adapt to this change. In order to assess international initiatives and their actions on the adaptation agenda, we can use the following three points as benchmarks.
First If international development initiatives continue to be effective as a means of promoting health and economic development, they must become better responsive to the changing needs of low-income countries. This may sound like a no-brainer, but it would require existing aid and health programs to focus less on donor-set indicators, such as disease reduction targets, years of primary education and poverty on less than a dollar a day, and more on the effects of programs on the ground, such as whether they produce governments capable of learning and governance, and the health of the population, especially the poor and vulnerable. Richard Cash, now a professor at the Harvard School of Public Health, co-invented the oral rehydration salt solution that saved many lives. At a 2013 conference dedicated to reducing global child mortality, he said:
If we continue to focus entirely on mortality as we do now, we will ignore many problems, such as water pollution, such as weak education systems... and a series of other vital development issues. We don’t want to see success in reducing mortality while people continue to live in abject poverty – as is already happening. Our tools are powerful, our vaccine is highly effective, and our interventions are exceptional, but we are not adequately addressing the underlying risks and underlying causes of mortality and morbidity.
Global health priorities must also include non-communicable diseases and related health risks.In low-income countries, these diseases are now the leading causes of premature death and disability. It is simply unsustainable to devote significant resources to fighting a range of treatable and preventable diseases, only to watch the same patients die prematurely from other preventable and treatable diseases. In 2017, the Determined to Save Lives Initiative was officially launched. This US$225 million initiative aims to improve the control of high blood pressure and high blood pressure in low-income countries. It is expected to attract the attention of more donors in the context of the increasing number of non-communicable diseases. The broad platform established by the U.S. government and other aid agencies to combat infectious diseases such as HIV/AIDS is also an asset. For example, most international initiatives targeting infectious diseases have established mechanisms to ensure the supply of affordable, reliable quality medicines; allowing low-income countries to use these corresponding mechanisms to purchase essential medicines for the treatment of non-communicable diseases such as cancer and diabetes would require the consent of donors such as the United States, the United Kingdom and the Gates Foundation. Supporting the scale-up of these global programs, which deliver life-saving goods and services, will be important, especially for the poorest slums and the most unstable countries, which face serious challenges from both communicable and non-communicable diseases.
The United States and other donors should reshape their global health assistance programs from setting goals around diseases to taking results-oriented measures to improve the health status of target countries and populations. Aid donors should strengthen accountability and capacity for global health investments by choosing targets based on health outcomes rather than reduction of specific diseases, taking a patient-centered approach, and investing in data collection efforts to monitor the process. Such a move would make global health programs more valuable and make it easier for governments in low-income countries to shift from relying heavily on external aid to implementing health programs on their own. Donors should ensure that developing countries have a greater say in the selection of outcome indicators, which will enhance their utility and increase the likelihood of their eventual local adoption.
The key to understanding how to advance the interests of disadvantaged groups is to listen to their actual demands. In 2015, Angus Deaton and Robert Tortora conducted a data analysis of the results of multiple opinion polls across sub-Saharan Africa and found that respondents prioritized improving their lives, such as finding new jobs, increasing land production, etc., rather than improving medical services. This does not mean that aid initiatives should stop prioritizing health, which is after all the area where aid is most effective. There is evidence that respondents' need for new health assistance has declined in part because the situation with infectious diseases has eased and because they are more satisfied with existing assistance programs. But it does illustrate the need for future health aid to be matched by investment in areas that can help companies and factories, large and small, employ their workforce efficiently.
Taking a results-oriented approach in education may also be beneficial. Lant Pritchett pointed out in his book "The Rebirth of Education" that the pursuit of 100% primary school enrollment has caused people to ignore the lag in efforts to achieve the fundamental goal of education, which is learning. The United Nations Sustainable Development Goals , released in 2015, include targets on teaching quality, but there is no consensus on how to measure progress. Many countries are reluctant to compare themselves to other countries, and there are often large differences between official literacy rates and what surveys show. An initiative announced by the World Bank in 2017 may lead to some positive changes. The agency will conduct a Human Capital Project, a transparent, evidence-based annual assessment that combines measures of health outcomes and teaching quality with a country's domestic productivity profile. The purpose of this is to encourage private companies to use the index in their foreign investment decisions, thereby creating incentives in the field of investment and financing and guiding the government to invest more resources in improving education and health conditions.
Prudent, targeted investments can also help low-income countries meet the demographic challenges posed by declining infectious diseases. In recent years, aid agencies have increased investment in voluntary family planning and girls' education. These aid projects have helped countries such as Senegal reduce fertility rates to more sustainable levels and allow women to better participate in the economy. Such investments should become more common. Recent actions, such as the Obama administration's Power Africa initiative, have encouraged private investors to participate in infrastructure projects such as power generation, making it easier for entrepreneurs to start businesses and factories to hire more young workers.
Second, charities and international aid agencies should be allowed to accept a smaller but still capable role in helping poor countries and emerging economies cope with the demographic challenges posed by declining infectious diseases. Their role should focus on stimulating and driving bottom-up change locally by funding data collection and research work undertaken by practitioners and activists. This work should include providing local researchers and governments with the resources and technical support they need to test the best ideas, and working with local stakeholders to translate the results into actionable, evidence-based projects. Where appropriate, external organizations can also play a role, by supporting social reformers to pressure governments to adopt better policies, and by holding local government and aid agencies to account through monitoring, evaluation and publication of results.
Bloomberg Philanthropies is a charity that has used this strategy to help promote tobacco control in low-income and emerging economies. For example, in 2008, Turkey increased tobacco tax to 81% of the price per pack, banned tobacco advertising and banned smoking in public places. The following year, Turkish hospital emergency admissions for smoking-related illnesses fell by nearly a quarter, and smoking rates fell by 16% in three years. Philippines has recently adopted similar reform measures. This data-backed, locally driven tobacco control strategy has withstood strong opposition from a multibillion-dollar industry and is working in both low- and high-income countries. There is no reason to think that this strategy cannot be used to promote reforms on other issues, such as more effective health systems, family planning, and improvements in the quality of girls’ education.
Third, politicians in high-income European and American countries must face up to the contradictions in their climate, global health, trade and immigration policies. The economies of many low-income countries are suffering as politicians fail to face up to the fact of climate change and its causes, which could threaten the progress already made in global health and could accelerate the rate of international population migration. For example, researchers have found a link between the effects of climate change—less rainfall and warmer temperatures—since 1975 and stunted growth among children in Kenya. Many rapidly expanding cities in low-income countries are located along the coast or downstream of large rivers, including Guayaquil in Ecuador, Ho Chi Minh City in Vietnam, and Khulna in Bangladesh—cities most vulnerable to flooding caused by global warming.
Politicians in European and American countries are increasingly relying on anti-immigration and economic nationalist policies to seek election office, and sometimes they get what they want. The will of voters should naturally be respected, but wiser politicians and policymakers would also recognize and explain the inconsistencies in these policies to voters rather than play on voters' fears. Trade protectionism destroys the opportunities for emerging economies to develop their economies and create jobs. In the short term, countries that have experienced reductions in infectious diseases in recent years will not be able to stem out-migration based on increases in income and employment opportunities alone, but these factors may shorten the duration and slow down the pace of migration. Voters in Europe and the United States can choose to be anti-trade or anti-immigration, but it is difficult to achieve both goals at the same time.
In a globalized world, few things stay local for long.What happens within any country's borders affects many other countries, and this is increasingly the case. This is clearly the case with the demographic challenges arising from the limited success of infectious disease control. Richard Haass, president of the US Council on Foreign Relations, called on more countries to accept the concept of sovereignty and government obligations, that is, governments have the obligation to control risks and policies within their territories that may have adverse effects on other countries. This philosophy, based on pragmatic self-interest and necessity, applies equally to the current situation. Low-income countries must act quickly to adapt to domestic demographic changes and seize the opportunities presented by improved health conditions. However, governments in high-income countries must also recognize their obligations and not undermine the efforts of low-income countries with short-sighted stances on climate change and overly restrictive trade and immigration policies. One good way to help low-income countries is to stop preventing them from taking appropriate measures to help themselves. In a world where the daily threat posed by infectious diseases is gradually disappearing, the idea of sovereign government obligations is a motto for intergovernmental cooperation. This idea, combined with the other suggestions presented above, could make the world not just a better place, but a less worrisome one.
Myths About the Benefits of Plagues Myths about the Benefits of Plagues
Historian Christopher Hamlin reminds us to be wary of "fallacies about the benefits of plagues." Some who hold this view claim that new outbreaks of infectious diseases such as cholera and tuberculosis may spur necessary investment in sanitation and other positive government reforms, as has happened in the past. I don't agree with this view myself. The lessons of past experience do not mean that it is too difficult to prevent and control infectious diseases and improve health for the poorest people, nor does it mean that developing countries have made premature progress in fighting infectious diseases, because no goal is more worthy of our pursuit than reducing unnecessary suffering and premature death of humans, especially children.
But in their efforts to improve health outcomes in low-income countries, many governments and nonprofits fail to think clearly. Infectious disease mortality is regarded by many as the primary indicator of progress. If low-income countries fail to simultaneously make greater gains in areas such as economic development, governance, education and infrastructure construction when this indicator declines, they will also face huge challenges. Only by better understanding the difficulties that exist in the path chosen to reduce infectious diseases can we more realistically perceive the serious challenges ahead and overcome these obstacles to moving forward.
(This article is excerpted from Chapters 5 and 6 of the book "Plague and the Paradox of Development". It is abridged from the original text. The pictures are also from this book and are released with the permission of the publisher)
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