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AIDS and the Ecology of Poverty$

Eileen Stillwaggon

Print publication date: 2005

Print ISBN-13: 9780195169270

Published to Oxford Scholarship Online: February 2006

DOI: 10.1093/0195169271.001.0001

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Opportunistic Investments for Health and Human Development

Opportunistic Investments for Health and Human Development

(p.211) 11 Opportunistic Investments for Health and Human Development
AIDS and the Ecology of Poverty

Eileen Stillwaggon (Contributor Webpage)

Oxford University Press

Abstract and Keywords

This chapter uses the economic concept of externalities to evaluate the positive spillovers that exist in health interventions. It argues for mainstreaming AIDS prevention by addressing a broad array of development problems, rather than by employing a just-in-time approach to HIV intervention. It demonstrates that non-health investments are often the best way to achieve health goals, such as increasing the efficiency of customs regulations at border posts to reduce the spread of HIV along trucking routes. It also argues for broad community health programs that exploit economies of scale and scope.

Keywords:   externalities, spillovers, development, non-health investments, borders, customs regulations, economies of scale, economies of scope

This book has made the argument that the AIDS epidemics in the developing world and the transition countries are neither random nor inexplicable events. They are the predictable outcome of an environment of poverty. Just as the health of the natural environment depends on a complex network of ecosystems, so, too, does the health of human populations depend on the interaction of numerous biological factors and their interplay with social, economic, and environmental circumstances that comprise the ecology of poverty.

In the face of myriad health problems in developing and transition countries and billions of dollars spent on HIV/AIDS prevention with little effect, the prospects for combating the AIDS epidemic might seem bleak. The message of this chapter, however, is optimistic. As daunting as is the list of necessary interventions to improve health in developing and transition countries, we already know what to do and how to do it. Furthermore, correcting the wide array of health and related human development problems is far more affordable, even profitable, than is generally recognized.

As we saw in chapters 4, 5, and 6, the conditions that increase the vulnerability of a population to HIV/AIDS are widespread in developing and transition countries. In spite of the unprecedented wealth in the world as a whole, the precarious existence of billions of people made the emergence of pandemic HIV/AIDS possible, through biological, social, and economic routes. The solutions proposed in most AIDS discourse for this biological (p.212) and economic disaster address neither the biological nor the economic causes of widespread transmission. The interventions that are now funded remain almost exclusively behavioral. Proponents of those policies argue that their methods are more economical because they are aimed directly at the act that leads to transmission of HIV from one person to another. But in few places are the epidemics slowing down. Why should we expect simplistic methods to solve complex problems? Furthermore, since poor people and poor economies have so many health problems that threaten their viability, why should we put all of our funds into preventing just one disease, one act at a time?

Synergies, bad news and good

Few diseases are monocausal or so virulent that they can spread rapidly without supporting conditions. Most epidemics require a supportive context of economic, social, and environmental factors. Even fewer diseases have purely behavioral causes. There are, of course, behavioral elements to virtually every disease transmission. Drinking contaminated water is a behavior, but one can hardly say that people get sick with cholera because they have a drinking problem. Becoming sick with cholera should not be viewed as the result of drinking behavior but of the infectious dose in the water consumed and the immune strength of the person consuming the contaminated water. Poor people have worse water, and they are less resistant. They probably do not drink more water.

Tuberculosis infection depends on the virulence of the cases around the person exposed to the disease and on that person's immune status. The problem is not the behavior of breathing, but where and with whom one does the breathing and the personal vulnerability of the person engaged in the breathing behavior.

As we have seen, the same can be said for HIV and other diseases that are transmitted sexually or vertically. Sexual contact or maternal infection is a necessary, but not a sufficient, condition for transmission. (The risk of infection through needle-sharing or blood transfusions is much greater, and the importance of cofactor vulnerability is consequently less significant.) Transmission depends on who transmits the virus (because identical behaviors produce different amounts of transmitted virus) and who receives it (how vulnerable a person is to infection). The viral load of the HIV-infected person is generally higher if that person is malnourished; has untreated bacterial STDs; has malaria, TB, or other diseases; harbors helminths and other parasites; is burdened with schistosome worms and eggs; or has other cofactor conditions. Having sex with a person who has one or more of those conditions is far more dangerous than having sex with an otherwise healthy HIV-infected person. An infant is more likely to become infected with HIV from the mother if the child is malnourished in utero, if the (p.213) mother has malaria, or if the child's immune system is activated by the mother's exposure to helminths and other parasites. Furthermore, all of those conditions weaken the immune status of HIV-negative persons. Exposure to the same amount of HIV virus, therefore, leads to sharply different likelihoods of contracting the infection between persons who are otherwise healthy and those who are burdened with malnutrition or parasites.

Not only are there numerous health conditions that contribute to vulnerability to disease, but also those conditions behave synergistically. Synergies make the impact of one condition more potent because of its interaction with others. For example, undernutrition is a serious problem on its own. Combined with contaminated drinking water, it can lead to more serious gastrointestinal results than in a well-nourished person, since the undernourished person lacks specific nutrients to resist disease-causing microbes in the water. Undernutrition combined with lack of vaccination can lead to catastrophic results from immunopreventable diseases such as measles. Measles depletes vitamin A, which is necessary for healthy eyes and resistance to infection. In vitamin-A-deficient children, measles can cause blindness and death. Malnutrition and parasite infection also have synergistic relationships (see chapters 2 and 3). As we have seen earlier, malnutrition and parasite infection also have a synergistic effect on HIV transmission. In the language of current discourse on HIV/AIDS, malnutrition and parasitosis are cofactors for infectious disease, including HIV/AIDS.

But synergies are not just bad news. They are opportunities for intervention. Adding vitamins or other nutritional supplements to a program for control of infectious or parasitic disease increases the effectiveness of the latter investment. In a parallel manner, providing antiparasitals or mosquito nets means that expenditures on nutrition programs are not wasted due to excretion of vitamins through diarrhea or burning calories through malarial fever. Investments in health, education, water and sanitation, transportation, and other sectors have significant positive spillovers in other areas.

Spillovers can be good or bad, or, as is the case with the health conditions discussed here, they have the potential of being both. The conditions have negative effects, but interventions to remediate them can have positive spillovers that are substantial. As discussed in chapter 8, the methods generally used in epidemiology and health economics to measure the effectiveness of health interventions are too limited to detect such spillovers. Cost-effectiveness studies rarely attempt to model more than a single input and a single output. Decontextualized analysis, such as randomized controlled trials or single-input/single-output cost-effectiveness analysis, is useful for some purposes, but it cannot be the only approach we use to examine complex ecologic questions. In order to prevent HIV/AIDS, we have to recognize and exploit the synergies that undermine health and well-being in general.

We know that good diet, clean water, worm elimination, and protection from schistosomes and malaria are good for people, and we know that the (p.214) effects of each individual intervention would be enhanced by any of the others. And we know that each of those makes people less likely to transmit HIV to others and better able to resist HIV infection if they are exposed. Healthy people also can evaluate information better and choose safer behaviors (within the constraints of their economic and social situation). Complementing these health strategies, economic interventions to eradicate poverty and provide economic alternatives expand those choices for people even more.

This book has shown that HIV/AIDS is indeed a development issue. The origins of epidemic AIDS in developing and transition countries can be found in the same weaknesses of those economies and social structures that produce so many other kinds of suffering. It has long been recognized that myriad aspects of underdevelopment interact in a vicious circle that thwarts efforts to raise living standards. In the macroeconomic and macrosocial environment there are synergies of underdevelopment. At the community level, too, social and economic factors interact with climate, history, and even chance to advance or retard human development. At the individual level, there is synergy as well, since nutrition, parasite load, exposure to pathogens, and access to health care interact in negative or positive cycles toward illness or toward health.

In the face of this global health emergency some have suggested that resources be ever more concentrated and targeted on interventions aimed solely at the immediate threat, HIV/AIDS. That has always been a mistake and continues to be a mistake even as the pandemic worsens. Every year more young people confront an environment with the same biological, social, and economic risks. At the same time, other analysts are claiming that poor countries will reach the limits of their absorptive capacity if too much help comes their way. Together those two arguments—spend only on HIV/AIDS, but only up to the limited absorptive capacity—save donors from spending much of the money that has been promised but abandon poor people to the same unhealthy environment.

In fact, there is no problem of absorptive capacity if the right investments are chosen. The solutions that this book would offer are perhaps by now obvious. The most cost-effective solutions are those that exploit the synergies that exist: biological, social, and economic. The most important investments for health might not be in the health sector, just as the most important investments for productivity in agriculture and industry are probably in the health of the labor force in poor countries.

Health and non-health interactions

Chapters 2 and 3 explored a number of health synergies, including those among nutrition, parasites, STDs, and tuberculosis. An important health and behavior interaction that cannot be included in cost-effectiveness stud (p.215) ies of single interventions is the effect that one health intervention has on other health behaviors. Survival from one disease provides incentive to invest personally in other preventive measures (Dow et al., 1997). In addition to synergies between different health conditions and between successful health outcomes and behavior, there are externalities between and among investments in health and other aspects of economic and human development (see chapter 8 on externalities). These interventions are needed to address HIV as a development issue, although they may be also, or even primarily, intended for other purposes. Because the HIV epidemic is neither random nor inexplicable, interventions to prevent or reverse it must be aimed upstream, as well as at the immediate causes of transmission. Education, agriculture, commerce, government, transport, and other sectors all shape the environment of health. The following section explores just a few of the ways that investments in human development have positive spillovers or externalities that have immediate benefit for individual and group health and development and long run benefits as well.

Nutrition and learning

A substantial literature supports the importance of good nutrition for learning. Certainly, the school breakfast and school lunch programs in the United States and other industrialized countries are in part based on the recognition of nutritional needs of children. They also attempt to increase school attendance by offering meals, since regular attendance is assumed to contribute to the learning process as well. Nutrition alone, however, is not as effective as combined interventions that exploit the interactions of better nutrition and a better learning environment (Sigman and Whaley, 1998). Another aspect of good nutrition that receives inadequate attention is the physiological impact on psychological well-being. Malnutrition promotes a sense of fatalism as a direct physiological effect. That fatalism undermines confidence in learning or other actions that would help to lift someone out of poverty. Confidence speeds learning, which then has a self-fulfilling momentum.

In particular for addressing HIV and AIDS, some upstream investments have value that has been little appreciated. Education of girls is important to develop productive workers; cultivate aesthetic, intellectual, and other capacities that are important in their own right; and reduce infant mortality. Children in school are a captive audience for HIV and other health-education programs. Girls in school are less likely to become pregnant, which might mean they are postponing sex. (For a review of the literature on the externalities of girls' education, see Schultz, 2002.)

Girls' education, however, is linked to community infrastructure. In order to keep girls in school, it is important to have easy access to water for the family, since the girls may spend several hours per day fetching water. Health has an important feedback on education because healthy children (p.216) are absent less often and are better able to learn when they are in school. Consequently, clean water supplies increase the state's return on its educational expenditure, the children's return on their time expenditure, and the parents' return on the opportunity cost of giving up the children's labor at home.

Another complementarity that must be considered so that keeping girls in school will have the desired effect of preventing HIV is that it is probably necessary to rescind school fees. The cost to parents of girls' schooling might be prohibitively high or just not valued sufficiently by them. Numerous works assert that schoolgirls have sugar daddies who pay their school fees in return for sex. If that is true, then canceling school fees is an easy solution to that part of the problem. The amount that parents are willing to pay for schooling for girls does not represent the full value to society of educating girls and protecting them and their children from HIV and other risks. This is an example of market failure, as discussed in chapter 8.

There are also intergenerational spillovers that are widely recognized. A mother's education has a significant effect on child survival and also on child development. The effect of mother's education on child height (an indicator of healthy development) is explained by improved access to information rather than through income. There is also a significant interaction between the impact of mother's education and the extent of infrastructure in her community (Thomas et al., 1991). Her capacity to use information is not of much use if the health-care facilities are not available. Complementarities abound for investment in human development.

Parasites and learning

An important adjunct to the literature on nutrition and learning is the research on parasite load and learning. Numerous kinds of parasites afflict a large proportion of the population of developing countries, as was discussed in chapter 2. Lack of clean water, sanitary facilities, clean storage areas for food, and adequate hygiene practices are among the reasons for endemic parasitosis. Many parasites produce significant morbidity in children and adults, but because they are rarely fatal, they tend to be underappreciated as a source of misery, as well as a cause of significant loss of productivity (Gallup and Sachs, 2000; Fischhoff et al., 2002). Numerous studies document the effect of parasite load on cognitive function, highlighting again the spillover effect of health on education, achievement, and community participation (Kvalsig et al., 1991; Nokes et al., 1992; Adams et al., 1994; Levav et al., 1995; Gallup and Sachs, 1999; Hastaning et al., 1999).

Miguel and Kremer expand the analysis of deworming programs and learning through the concept of externalities. They found that children who were treated for worms increased their school attendance. Furthermore, untreated children in the same school and even untreated children in nearby (p.217) schools without treatment benefitted and increased school attendance because their play areas were less contaminated with excreted worms. The single-dose therapy can cost as little as 49 cents per person per year. The treatment was the most cost-effective way of increasing school attendance, and the authors conclude that the externalities in community-wide health improvement justify fully subsidizing treatment (Miguel and Kremer, 2001).

Anderson and May reported similar externalities in treatment of schistosomiasis. They found that treating “a random ten percent of the local population would lead to a 37 percent reduction in the total local worm burden, with over three quarters of this reduction due to the externality, while mass treating a random 30 percent of the local population against worms would lead to a reduction of 89 percent of the total local worm burden” (cited in Miguel and Kremer, 2001, 21–22). Miguel and Kremer argue that naive estimates that ignore externalities severely underesti-mate cost-effectiveness: “To the extent that the treatment of other tropical infectious diseases also generates spillover benefits similar to deworming, the externality findings of the current study may also provide an additional rationale for a substantial public role in subsidizing medical treatment for infectious diseases in less developed countries” (Miguel and Kremer, 2001, 44).

Treating children for worm infestation makes them healthier, eliminating a constant challenge to their immune system and the constant drain on their nutrition. Treating a single child, however, affects many others. Reducing the diarrhea that worms produce reduces the number of other children who will become infected with worms since they are spread through fecal contamination of play areas and drinking water. The mother's and siblings' time spent in caring for the sick child is now freed up to produce food or contribute to the family in other ways. The child is able to attend school, and the community as a whole benefits from having one more educated member. Given the new information on worm infection and vulnerability to HIV transmission (see chapter 3), the urgency to relieve over 1.5 billion people of this serious obstacle to health and well-being becomes even greater. Treating worm infection is an effective and inexpensive measure that could slow the HIV/AIDS epidemic, with important collateral benefits in the health, comfort, and productivity of a large segment of the world's population.

Other benefits of parasite eradication

There are other examples of positive spillovers from health investment into other sectors. Programs for the eradication of river blindness and the control of tsetse flies opened up millions of acres of farmland and pasture, expanded agricultural potential, with a feedback for food security. Eradication of dracunculiasis (guinea worm infection) has the collateral benefit of providing (p.218) clean drinking water, which prevents other parasitic and infectious diseases, and the training of community health workers who can deliver other health services (Aylward et al., 2000).

Malaria-related illnesses kill 5 percent of children under age 5 in sub-Saharan Africa, which means that mothers must replace 5 percent of births to achieve the desired number of children. The mortality rate among adults is lower, but malaria saps productivity through frequent episodes of fever (McCarthy et al., 2000). Malaria has a significant effect on economic growth through various routes, which likely include “the effect of repeated worker absences on production patterns and specialization, malaria-prevention motivated reductions in internal and external labor mobility, and potential loss of investment projects” (McCarthy et al., 2000, 6). Other growth effects of malaria include work absenteeism, coping required of coworkers and family members, school absenteeism, losses in long-term learning capacity, and losses in accumulation of capital. Because of frequent absenteeism, firms have to overstaff and workers have to be less specialized. In agriculture, frequent illness of family members forces farmers to change planting patterns (McCarthy et al., 2000).1

In the case of endemic diseases, the effect on economic growth is largely invisible because of the factors that are never measured. Diseases that are always there are built into investment plans or the decision not to invest. Only the scale of the AIDS epidemic and the high profile it had achieved in the United States and Europe brought adequate worldwide attention to the effect of health on economic growth in developing and transition countries. There are scores of studies of the economic burden of guinea worm, river blindness, hookworm, and malaria. The puzzle is why the weight of such evidence has not been enough to mobilize resources for eradication of all those diseases, or why there is still any question about how to help countries develop. The solution, or at least a large part of the solution, to HIV is to solve the myriad other problems that afflict poor people in the developing world and hinder human development. HIV did not develop in a vacuum, and it will not be stopped in isolation.

The obligation of optimism

Development programs were molded by the perspective and interests of affluent countries. That had a direct impact on HIV/AIDS because it kept (p.219) policy makers from seeing the obvious: that we still have not secured a dignified safe standard of living for half the world's people. This time it is AIDS, but before it was cholera and next it may be flu, or something else. The route from poverty to death can be direct, or it can be mediated through behaviors that people are compelled to adopt or that they choose to adopt, but in either case, they are behaviors that are conditioned by their environment.

The environment of poverty is complex, but the solutions are rather simple to the extent that we know what investments directly improve people's health and freedom and that also help to prevent the spread of HIV. There are countless ways to intervene, in every sector. Many of them are costless, at least in financial terms. The good news is that so many of the required interventions have synergistic effects that the package of programs will actually cost less, and have greater impact, than is currently projected. All of them bring about improvements in the quality of people's lives that we should not have left until now.

We can't throw up our hands and say it can't be done. The truth is that we have the means. And the scandal is that all this suffering results from the failure to allocate resources to human needs and the failure to challenge oppressive systems.

There is no problem of poor countries being able to absorb the right investments. There is no problem of gender relations that cannot be attacked immediately. There is no culture in Africa, Asia, or Latin America that makes poverty there any more acceptable than it is in the rich countries. The fundamental differences are not between people but between the environments in which we live—and that we can change.

This chapter concludes with a dozen plans that contribute to HIV prevention. The goals sound ambitious, but we already have the knowledge and the tools required. In most cases the organizations already exist to execute the needed investments. The first plan is for eradication of helminth and Schistosoma infection. It aims to achieve a health goal with a health-sector investment. The rationale for eradication is abundantly clear from the foregoing discussion. The outlines of the plan are given in Objective #1. The second plan aims to achieve a health goal with a nonhealth investment. The rationale and approach for Objective #2 are provided, then the outlines of the plan. Ten more outlines follow.

Objective # 1

Objective: Eradicate helminth and Schistosoma infection

Methods: Cheap, effective deworming medications and hygiene education

Intestinal worms (hookworm, roundworm, and whipworm) can be eliminated with a single once-a-year pill. Either albendazole or mebendazole (p.220) can be used, and the cost is US$0.02 per capsule. Mass treatment is advised, requiring no diagnostic resources, because the treatment is easily tolerated (Montresor et al., 2001; World Bank, 2003b).

Cost per child per year of deworming (hookworm) is US$0.08 (Stoltzfus et al., 1998).

Schistosomiasis can be treated for US$0.20, once per year, using a single dose of praziquantel. Dosage can be determined on the basis of a child's height through a simple dose-pole. Teachers can be trained easily, making administration in school feasible and cheap. Teachers already have the means for keeping records on children. Deworming pills have a long shelf-life and are heat stable, allowing easy delivery in the tropics (World Bank, 2003b).

Recommended complementary investment: Water systems, latrines

Problems alleviated:

  • Malnutrition due to worm infections

  • Cost-effective in reducing moderate and severe anemia (Stoltzfus et al., 1998).

  • High work and school absenteeism

  • Poor school performance and early dropout

  • Externality infections, even in untreated population

  • HIV/AIDS cofactor eliminated

Sources of technical advice and aid:

  • TDR (Special Programme for Research and Training in Tropical Diseases), an organization sponsored by UNICEF, UNDP, World Bank, and WHO, at http://www.who.int/tdr

  • World Bank, at http://www.worldbank.org/hnp

  • PPC (Partners for Parasite Control) founded by the World Health Assembly in 2001

  • Bill and Melinda Gates Foundation

  • Carter Center

  • Partnership for Child Development

Note: The significant externalities between education and hygiene and of labor productivity on both education and hygiene make this a particularly good investment.

Solving a development problem with economic and health impact: trade and trucking

Sometimes the best investment to solve a health problem will be outside the health sector. There are countless ways to promote development and reduce the risk of HIV transmission. In every sector—agriculture, industry, commerce, government, education, and others—there are opportunities to (p.221) make the changes that should have been made long ago, and that could have helped to prevent the health crisis in the developing and transition countries. This section proposes the modernization of trucking and trade, as just one example of obvious ways to help prevent HIV transmission while achieving other worthwhile goals.

Lengthy delays at border crossings are repeatedly mentioned in the policy literature as contributing to HIV transmission, particularly in sub-Saharan Africa. It is clear that border delays are costly in themselves, even if HIV did not exist. Well-developed trade corridors are essential for the flow of goods and also for the diffusion of new technology, both of which contribute to job creation and opportunities for higher incomes in the hinterland. Border delays raise the cost of shipping and discourage investment. Some goods, including agricultural products, are not worth shipping because of the unpredictability and high cost of delivery. (A longer list of the cost of border delays appears in chapter 9.)

The knowledge of how to facilitate trade is already well established. One need only travel from Eastern Europe, where as many as 50 trucks are lined up at border crossings at any given time,2 to the European Union to see that borders need not be an obstacle to the free flow of truck traffic. Of course, there are numerous historical and political obstacles to the free flow of goods and factors of production across international borders. Most developing countries have elaborate and suffocating trade barriers that are intended to protect domestic industry. An ideological hostility to free trade on the part of many people concerned with human development has hindered the promotion of trade facilitation for poverty eradication. The vested interests of those who collect bribes and fees also support the system. Rarely in the last 40 years, however, have those restrictive systems promoted domestic growth and development.

This is not the place to evaluate all the arguments for and against protectionist trade policy, generalized or specific. It is safe to say, however, that little is to be gained from competitive restrictions between similarly impoverished countries. That is true for poor landlocked states, such as Zambia, Zimbabwe, Botswana, Lesotho, and Swaziland, and for countries with good ports but few products or just one product to export, such as Mozambique and Angola (Lakshmanan et al., n.d.). Cooperation, rather than competition, between countries such as Zambia and Zimbabwe, would have beneficial results. Even between countries unevenly developed, such as Zimbabwe and South Africa, integration offers numerous advantages. South (p.222) Africa already relies on labor migrants from throughout southern Africa, and the other countries depend on remittances from workers who migrate south for work.

The Maputo Corridor provides an example of the benefits of connecting the interior to the coast. The Southern African Development Community has been trying to revive the Maputo Corridor to provide a shorter route to the ocean for goods from Johannesburg and to help Mozambique. The route would lower prices for imports inland and lower the cost of shipping exports. Intermediate goods could move more rapidly among regions, and along the corridor new sources of employment would provide opportunities at home to discourage migration to the largest cities. Transport development would also lead to the improvement of water and sanitation in communities along the way. The physical infrastructure of a road system will be wasted, however, if it is not accompanied by smooth border operations and good logistics (Lakshmanan et al., n.d.).

The European Union is built on the principle that market integration is beneficial. The larger market offers opportunities predicted by all the theories of international trade. Even if the integration of poor countries represents only the pooling of poverty, however, and none of the growth promise of the EU, it is still worthwhile to reduce the costs of trade barriers. These countries receive no growth stimulus from the border regulations. The costs of those regulations are numerous, including the costs to the government of maintaining the system, the private costs listed in chapter 9, and the pervasive corruption and its insidious effect on good governance, efficiency, and personal incentives. To all that we must now add the mushrooming costs of the AIDS epidemic, which is partly fueled by border delays.

Border regulations could be dismantled in a very short time. The system does not need to be invented. The EU has 40 years' experience with progressive trade facilitation. Removing trade barriers between developing countries need not take anywhere near that long because the process is already well known.

North America already has computerized systems for paperless truck logs and truck surveillance systems that allow trucks to maintain highway speeds while passing weighing stations, ports of entry, and agricultural inspection stations (see PrePass at www.prepass.com). The International Chamber of Commerce (ICC) also has a well developed program for trade facilitation, including paperless customs procedures and other border surveillance, such as agricultural and security checks (www.iccwbo.org).

There is a very valuable opportunity here for the Bill and Melinda Gates Foundation or other funding groups to modernize trucking and trade by financing the computerization of customs for the trade corridors in Africa, Asia, and Latin America. Low national income is not an obstacle to trade facilitation. India is computerizing truck checks at state borders. The intention was probably to reduce corruption, a worthwhile goal. But the (p.223) new procedures also improve oversight and increase profits in other ways, including reduced travel time, lowering capital and labor costs for shippers (Nachiket Doshi, personal communication). Compared with the economic and health costs of border delays, a laptop computer and a transponder for every truck are a small investment.

Objective # 2

Objective: Alleviate border delays


  • Paperless customs procedures

  • Barrier-free trade among developing countries

Problems alleviated:

  • Long stays away from home for truckers

  • Costly delays for trucking and shipping firms

Sources of technical advice and aid:

  • International Chamber of Commerce

  • World Bank

  • European Union

  • Bill and Melinda Gates Foundation

  • PrePass

Ten more plans for health and development

This section gives ten more examples of obvious, important interventions that should be undertaken in order to enable people to live healthier, freer lives and to prevent HIV transmission. The selection is not meant to be limiting but, rather, suggestive. People in every sector will think of similar interventions they can undertake. The ways to promote human development and lessen vulnerability to HIV epidemics are already known; they just have to be funded and carried out.

Objective # 3

Objective: Bolster immune systems

Methods: Cheap, effective nutrient supplements

  • Vitamin-A fortified sugar: US$0.29 per person per year (this adds only 1.6% to the price of sugar) (Sommer et al., 1996)

  • Vitamin-A capsules, US$0.02 per capsule (Sommer et al., 1996)

  • Iron supplementation costs US$0.02 per child per year if given weekly, or US$0.08, if given daily (Stoltzfus et al., 1998).

  • (p.224)
  • Iron supplementation increases the efficacy of iodine supplementation (Hess et al., 2002).

Sources of technical advice and aid:

  • Sommer, Alfred, and Keith West, with J. A. Olson and A.C. Ross. 1996. Vitamin A Deficiency: Health, Survival, and Vision. New York: Oxford University Press.


  • United Nations Food and Agriculture Organization

  • International Food Policy Research Institute (IFPRI)

Note: A healthy population is a public good since it is beneficial to everyone but is not within the means of any one firm to finance. Government attempts to compel the food industry to absorb the full cost of vitamin-fortification programs have failed (Sommer et al., 1996, 419).

Objective # 4

Objective: Keep girls in school

Methods: Eliminate family burden for school fees

Problem eliminated: Sugar daddies for school fees

Sources of aid: Faith-based organizations in wealthier countries

Note: This is an excellent activity for faith-based organizations since some are reluctant to finance HIV-prevention programs that entail controversial issues of sexuality. Faith-based organizations should readily finance school fees. Individual mosques, synagogues, or parishes could adopt one or a number of schools, or a large organization, such as Lutheran World Relief or Catholic Charities, could adopt an entire national school system. Concerns about the participatory aspect of user fees can be resolved through students' contribution of time, such as tutoring younger children, caring for school gardens, and so on.

Objective # 5

Objective: End oppression of women

Methods: Behavior-change communication through government, school, religious, and community campaigns

Problems alleviated:

  • Violations of human rights

  • Child and maternal mortality due to women's lack of control over income, food, health decisions

  • Inability to negotiate safer sex

  • (p.225)

Sources of aid:

  • Religious organizations

  • Government

Note: In this matter it is essential to involve religious organizations. They all claim to be in favor of the equality and dignity of women, at least in the home. All of the things they detest—pornography, sex work, casual sex—are supported by the low status of women. If they want to protect the sanctity of the family, they must support the equality of women in the household. To ignore the practice of husbands using sex workers or having mistresses is to collaborate in gender inequality. In Latin America, for example, it is common for men to stand outside on the steps of the church while women and girls attend Mass. The priests need to stand outside with the other men and take their message out there. If the men leave, the priests should follow them and talk to them in the bars. The religious groups—churches, mosques, or temples—have to lead the campaign for gender equality so that it is more than a theoretical part of their faiths and so that they can have a positive influence on change. At present, some people use religion as an excuse to prevent gender equality.

This seems like a very large agenda. Nevertheless, how will it be accomplished if it is not begun? Furthermore, it is not as formidable as it seems. It does make a difference to change the legal status of women and to have faith-based organizations support women's equality. Completely changing men's views and women's status will, of course, take time. But a combination of BCC and regulatory enforcement has been used successfully against problems as varied as tobacco use, drunk driving, and littering. To accept that we are powerless against sexist oppression is to grant it a special status that is unwarranted and incorrect.

Objective # 6

Objective: Extend health care services


  • Use Global Fund money to expand primary-care networks

  • Provide mobile clinics in buses, trains, boats

  • Use religious and community buildings for part-time and visiting clinics

Problem alleviated:

  • Lack of primary care

  • Lack of health-promotion consciousness

  • Lack of venue for HIV education and administration of antiretroviral medication

Sources of technical advice:

There are numerous models for community-based comprehensive pri (p.226) mary health care. In Maharashtra State in India, Doctors Mabelle and Raj Arole built a system of health care through training community health workers. They accomplished social and medical goals simultaneously by training Dalit (so-called untouchable) women to be health workers. The caste barriers were overcome because people wanted the health services that only the Dalit women could provide (Arole and Arole, 1994).

Mobile clinics have been found to allow very efficient use of health staff time. Calculating all costs, including travel costs of patients, mobile clinics definitely reduce cost per contact. Travel costs are especially high for mothers who are part-time wage workers because they have to give up work to go to a clinic. Mobile clinics also increase coverage of the population (Vos et al., 1990).

Objective # 7

Objective: Mass communication for health information

Methods: Radio, television, street theater

Problem alleviated: Lack of information about healthy living and about personal rights

Sources of technical advice and aid: Communication Initiative. The Web site and mailings of the Communication Initiative have extensive information on and models for using communication for health and other social objectives (http://www.comminit.com).

Some models: As with community health care, there are many good models of health education using the media. One example of effective communication of health information in a readily available format on a variety of topics is the radio show, nationally syndicated in the United States, “Cuidando su Salud.” The program is relatively inexpensive to produce, is well planned for the target population, and covers a range of health topics. There are several features of the programming that make it successful: repetition of key themes, long enough format to be really informative, no use of jargon, a constant feature of the daily news, and sensitivity to community views (Huerta and Weed, 1998).

In Tanzania, radio soap opera was used to educate and change attitudes and behaviors for HIV prevention. In the absence of a conscious preventive message, in television and radio there is already a message about appropriate behavior (Vaughan et al., 2000).

Objective # 8

Objective: Change in hiring practices and status of women at work

Methods: Behavior-change communication

Target: Corporate and government managers

Problems alleviated:


  • Waste of workforce

  • Abusive attitudes toward women in the workplace and community

  • Higher incomes for women improve their options vis-à-vis partners

Sources of technical advice and aid:

  • Global Business Coalition


Note: The Global Business Coalition has already developed the network for assisting businesses to train managers for BCC programs for workers. What is needed is BCC for managers to make fundamental changes in hiring practices and in respect for women in the workplace. Employers can enforce behavior in the workplace. Both the Global Business Coalition and USAID already promote behavior-change communication. They just have not applied it to fundamental change in the way managers approach their jobs. Behavior change should not be limited to people whose economic status is subordinate.

Objective # 9

Objective: Eliminate trafficking of women and children


  • Criminalize soliciting but not prostitution

  • Close brothel towns


  • Organized crime groups

  • Police who abet gangs

  • Clients

Problems alleviated:

  • Source of HIV and STDs

  • Other effects of slavery

  • Social dysfunction in consuming countries. Industrialized counties are ignoring social problems at home (distorted gender relations and pedophilia) by tolerating trafficking, sex tourism, and Internet shopping for sex tourism.

Sources of technical advice and aid:

  • Interpol

  • International Office for Migration

  • Human rights groups

  • (p.228)

Objective # 10

Objective: Sustainable agricultural systems in developing countries

Methods: This is obviously a complicated issue, but one thing that can be done, regardless of climate, labor resources, technology, and so on, is for the United States, Japan, and the European Union to drop their tariff barriers that make it more difficult, if not impossible, for poor countries to compete in developed-country markets.

Problems reduced:

  • Rural and urban employment

  • Famine

  • Excessive urbanization

Source of technical advice: World Trade Organization: the system is there; it has to be used against the tariff walls that do the most harm—tariffs of industrialized countries against developing-country imports. Industrialized countries are exporting their agricultural-sector problems to the Third World, as they export their social problems by not addressing distorted gender relations, and their labor shortages by recruiting nurses from developing countries.

Objective # 11

Objective: Blood screening, safe needles in medical and quasi-medical settings

Problem alleviated: Transmission of HIV as well as numerous other infections, including hepatitis B, Hepatitis C, and Chagas disease

Sources of technical aid and advice:

Objective # 12

Objective: Reuniting families

Methods: Bus service. It would, of course, be preferable if families could live together close to their work. Mine, factory, and plantation managers should make every effort to enable workers' families to migrate with the workers and organize services so that family members can also find work. If it is impossible for family members to accompany workers because they are tending family farms, then easy, cheap transportation should be available. There are extensive bus services throughout Africa, Asia, and Latin America. But as anyone knows who has traveled by bus, indirect routes can use up (p.229) all the free time one has. Migrant labor is essential to the operation of those firms. The workers' value should be acknowledged in the services provided to them by the firms. Since many migrants come from the same regions, it is not that difficult to run bus services that are easy to use. Firms in the same area can cooperate in organizing the pools. Work time could also be reallocated so that workers have four 10-hour shifts and can spend 3 days of every week as part of their families and communities.

Problems alleviated:

  • Divided families

  • Shortages of rural labor at peak times

  • Boredom and isolation at work sites

Sources of technical aid and advice:

  • Commuter van services, such as those organized by Commuter Connections in the metropolitan Washington area or any other urban area, http://www.mwcog.org/commuter/ccindex.html

  • College ride boards

  • Any of the thousands of van services that operate, often in the informal sector, throughout the developing world

Create your own models. Use the Blank Plans at the end of this chapter to devise strategies for your own sector or to correct a problem that you have seen. Photocopy the template or vary it to suit your plan, since you can probably think of many more interventions.

There are plenty of other examples of problems with easy solutions. See below a partial list of fairly easy but extremely beneficial actions or resources:

Four relatively uncomplicated legal changes

  • Abolish school fees

  • Eliminate border restrictions

  • Allow women to inherit land

  • Change immigration laws to encourage families to migrate with workers

Four cheap health expenditures

  • Deworming medications

  • Vitamin and mineral supplements

  • Treated bed nets for mosquito protection and malaria control

  • Water filters made from buckets or other simple materials

Four unused, misused, or underused institutions

  • Religious groups

  • World Bank


  • USAID, its partners, and other bilateral aid organizations



(1.) When I taught at the University of Dar es Salaam in Tanzania, the department always kept two professors in reserve, without course assignments. They knew that during the year every member of the department would come down with malaria at some point and would need to be replaced for a period of time. The prediction did prove true for all except the two expatriate professors who were taking malaria prophylaxis.

(2.) In spring 2003, I crossed borders many times among all the countries between Estonia and Croatia. Each time I would count the trucks waiting to clear customs. Often their number exceeded 50, whether at major crossings or on small roads off the main routes. When I visited the truck lots at Messina, South Africa, in 2005, I counted well over 200 trucks waiting to be cleared to enter Zimbabwe.