Tuesday, March 03, 2015

Railroads in Africa

There is an interesting article in The Economist on the boom in railroads in Africa. The map shown above, from that article, suggests that the network in East Africa is growing nicely and will provide some real benefits to the region; railroads are really low cost means of transportation, and will mean better costs from imports and lower shipping costs for many exports from the region. I recall being told in Uganda a decade ago or so that most of the railroads in that country were no longer running. Lets hope that the new arrangements work better than did those left from colonial days.

Are the new UN goals for reduction of poverty realistic?

I quote from a column in The Economist. The United Nations
is deservedly proud of having already met its goal of halving the share of people living in extreme poverty by the end of this year, compared with the level of 1990. In fact, the milestone was reached five years early. In 1990, 36% of the world’s population lived in abject poverty. By 2010 this was down to 18%. In absolute terms, the number of those in such desperate straits has fallen from 1.9 billion to about 1 billion today.
Unfortunately, looking at the goal of eliminating extreme poverty by 2030:
The case that this goal is feasible rests on extrapolations from the economic performance of the past few decades. One approach is to assume that the global poverty rate continues to fall by roughly one percentage point a year, as it has since the 1980s. That would take it below 3% before 2030. If that sounds a little crude, a second method involves simulating the effects of a range of growth rates. The poverty target would be achievable as long as consumption per person in developing countries increases by around 4% a year, roughly the pace it has achieved since 1999. 
Yet recent research from the World Bank itself casts doubt on both of these approaches.* The first projection—that poverty can keep declining by one percentage point a year—is the easiest to dismiss. The chart shows the distribution of spending by people in the developing world in 1990 and in 2011. In 1990 there was a big bulge of people spending just less than $1.25 a day. It took a relatively small boost from growth to lift this group over the threshold. But the people in the bulge are now largely out of extreme poverty; it will take ever-increasing amounts of growth to raise those lower down the scale to the same level. Most of the people still in penury live in countries with chronically weak economies or belong to marginalised groups, suggesting that it would be unrealistic to expect steady advances in their welfare. 
The second projection (based on sustained 4% growth in consumption per person) does take the existing distribution of global poverty into account. But Nobuo Yoshida, Hiroki Uematsu and Carlos Sobrado of the World Bank have pointed out three other flaws. First, the projection assumes that population growth is even across developing countries, when in fact it is higher in the poorest countries than in more prosperous spots. Second, it assumes uniform growth in consumption, but growth rates in the poorest countries, particularly in sub-Saharan Africa, are slower. Third, it assumes constant levels of inequality, when growth in developing nations often comes with increased inequality.
The assumptions appear unlikely to be fulfilled.

Extreme poverty is defined as income of $1,25 per person per day (2005 dollars) or $37.50 per person per 30 day month. Two adults living on $75 per month don't have much of a life, and it is hard to see how they might get by on less. A family of four would presumably have $150 per month, and that seems better until you start thinking of medical expenses, school expenses, and all the rest.

If the Congress Doesn't Legislate, the President Can't Veto

The Economist shows us that the number of bills passed by the Congress has decreased over the last half century, but the last Congress set a record. Obama is setting a record low rate of vetoing, but then he has very few bills passed by Congress that to veto.

Sunday, March 01, 2015

Analysis of the Burning of Columbia. South Carolina

Yesterday I watched a discussion of the burning of Columbia, South Carolina on History TV. The fire, which took place on February 17, 1865 has played an important role in the story the people of South Carolina tell themselves about the history of their state (although it is less famous in the country as a whole than the earlier burning of Atlanta, Georgia -- made famous in Gone With the Wind).

It seemed to me that an analysis of the failures leading to the destruction by the fire would give a different picture than did the panel in the discussion.

It seems that the immediate cause of the burning of the buildings was a fire that started in a large number of bales of cotton that had been piled on State St., the major street in the city at the time. The ropes that held the bales together had been cut so the cotton was loose. There was a high wind that fanned the flames and carried the burning cotton balls onto the buildings.

There are several possibilities as to how the fires were started in the bales:

  • They could have been started on orders from retreating Confederates to keep the valuable cotton out of the hands of the union troops:
  • They could have been started on orders of General Sherman to destroy valuable property of the Confederacy:
  • They could have been started by soldiers without such orders, probably by Union soldiers, many of whom were reported drunk;
  • They could have been started by others, such as former slaves celebrating their new freedom or by disaffected private whites.
Apparently no written orders have ever been found from either the Union nor the Confederate side. We will probably never know who started the fire in the cotton.

There were fire fighting units in the 19th century. Why did the Charleston firefighters nor the Union soldier put out the fires when they first started? Perhaps this could be attributed to the "fog of war". Many of the citizens of Charleston had left the city, and perhaps the firefighters were no longer present or no longer organized to take rapid action. Similarly, perhaps the danger of the fire in the cotton spreading to the buildings had not been recognized in time, or perhaps it had not been possible to organize the Union troops to fight the fire as they were taking control of the city and celebrating their victory.

Why was the cotton brought into the streets of Charleston and cut free from its bales? This seems to be clearly down to the orders of the Confederate officers who thought that they could thus deny the cotton to the Union troops.

I note that brick and stone buildings with slate or tile roofs, separated one from another are not likely to burn down in city wide fires. Charleston was apparently built in such a way that its business district was vulnerable to large scale conflagration. Perhaps a city built to a different code might have better survived.

Perhaps this was another "perfect storm" in that several things had to go wrong simultaneously for the city to be so badly destroyed.

Thursday, February 26, 2015

Did You Know This About Measles"

I quote from the Washington Post article that is the source of the graph:
Measles killed 82,100 children under age 5 in 2013, ranking the disease at No. 7 on the list of the top causes of child death, according to recent statistics from the Global Burden of Disease study published in the Lancet. Lower respiratory infections like pneumonia were the number one killer, followed by malaria, diarrhea, nutritional deficiencies, congenital defects and meningitis. More small children died from measles in 2013 than died from drowning, road injuries or aids.
I suppose the good news is that diarrhea is less lethal than it once was.

More than 80,000 little kids dying of measles in 2013 is an indicator that people carrying the disease are still going to be coming to the USA frequently. It is important that we keep up the immunizations to a very high level to maintain herd immunity. That way, even if a foreign visitor with measles arrives or a U.S. traveler with a compromised immune system returns to this country with measles, the disease won't spread. Incidentally, parents protecting their children with the MMR vaccine have the benefit that their child will not suffer from measles -- a potentially fatal disease. Moreover, the kid won't get mumps nor German measles.

By the way the huge death toll in developing countries from pneumonias, malaria, diarrheal disease, malnutrition and other causes is an ugly testimony to how little we care about others.

Wednesday, February 25, 2015

Poverty is not going down in Latin America.

I quote from the article in The Economist that is the source of this chart:
FOR many Latin Americans the 21st century has been a time of unprecedented progress. Between 2002 and 2013, 60m people in the region moved out of poverty. The poverty rate—the share of people living on less that $4 a day—fell steadily. Now the progress has stopped (see chart). For the past three years, the poverty rate has stayed stubbornly at around 28% of the population, according to household surveys collated by the UN Economic Commission for Latin America and the Caribbean (ECLAC). The proportion that is extremely poor (with a daily income of less than $2.50) has edged up, to 12%.
I lived in Latin America as a Peace Corps Volunteer, paid at the poverty level, but I also had free medical attention, and an additional $75 per month enforced saving that came to me at the end of two years service. I was not dependent on my income to raise children (and my wife, another Peace Corps Volunteer, received equal pay to mine -- and two live better on two poverty wages than one does on one poverty wage). Trying to live a decent life on $4 per day would be really hard. I think it would be impossible on $2.50 a day in Latin America.

It is really worrisome that progress on alleviating poverty has stopped, especially as the global economic system has not really been all that bad in the last few years.

A Major Technological Shift in Transportation

An article in The Economist predicts that hybrid cars are going to increase market share worldwide as are all electric cars at the expense of all fossil fuel cars. Electric motors for automobiles will replace internal combustion engines (I guess) as battery technology improves and as fossil fuels become harder to obtain and thus more expensive. The Economist seems to think it will take a long time for the shift to be completed.

Why Health Planning Didn't Work -- and When It Did

Plans are nothing; planning is everything.
Dwight D. Eisenhower
In a previous post I mentioned my participation in a health planning research project in the early 1970s. Prior to that project, for a decade or more, the PAHO CENDES health planning method had been disseminated throughout Latin America; more than 2000 health officials had been trained in the method. While that had a beneficial  impact of alerting many officials and health organizations of the need to do more, it seemed to yield few useful plans.

In all, I spent something like eight years thinking about health planning in developing countries as an occupation. I worked in a number of countries, visited others, and had colleagues who worked in still others and told me what they found. I noticed some interesting things:

  • Critical decisions were often about the construction of hospitals and health centers. Once built, these required staffing and budgets. The decisions seemed often to be political. In the Dominican Republic, for example, the dictator Trujillo had all the health centers built during his presidency built in the form of a "T" so that each would support his reign. Even when it was determined that a growing city needed a new public hospital, the decision of exactly where in the city would result in economic benefits for those who owned the land on which it would be built and indeed for those who developed surrounding areas and those who built the facility. I think the choice of location would then become political. So too, a newly elected legislator might try to get a health center approved and built in his district to bolster his chances of future election. A formal plan might not have much influence over such decisions.
  • Manpower allocations were less formal than one might think. Of course a new hospital or health center would have a table of organization with so many doctors, so many nurses, nursing aids, and other workers. But then there would come a need for a doctor in a hospital, and someone would tell a doctor on the nominal staff of another hospital to go work where he was more needed; no formal changes would be made in the staffing pattern. Then there was corruption. For example, a senior official would issue instructions that someone be added to the staff roll of a regional hospital even though he was living in the capitol city or in another country, with no medical responsibility at all. The formal written plans simply didn't catch up or didn't count.
  • I found a major, apparently modern hospital that did not have a modern cost accounting system. The heads of departments knew the direct budgets of their departments, and the senior staff knew all the direct costs. However, there was no accounting of indirect costs. For example, the internal medicine department knew the number of patients it treated and the costs of the salaries of its staff, but did not know how much the drugs it prescribed, nor the lab tests it ordered, nor the x-rays it ordered cost the hospital. Thus there was no way that total costs per service could be monitored, much less controlled.
  • Students I taught did a study of Ministry of Health pharmacies in our region. They discovered that a significant portion of the prescriptions sent to those pharmacies could not be filled because the required drugs were not in stock; on the other had, a significant portion of the stock languished on the pharmacy shelves for very long periods since it was not in demand. There was no adequate system for managing the inventory and ordering of drugs. In another country, having lunch across the street from a hospital, I watched as a shipment of pharmaceuticals was delivered, and then as another truck pulled up and reloaded the pharmaceuticals; I was told that they would be delivered to a private drug store to be sold on the open market. In still a third country,  a consultant we had hired to look at pharmaceuticals quit informing us that he had had threats against his life, and that apparently the organized illicit drug industry also controlled the local pharmaceutical wholesalers.
You can see that in systems with such gross malfunctions, health plans based on a theory of efficiently meeting health needs had little chance of being implemented. If a system is not well managed, it is not likely to be well planned.

A Counter Example

The USAID mission in the Dominican Republic was interested in the possibility of a health sector loan to that country. I was working in the Office of International Health at the time, and we were asked to help them look into that possibility. We had in process a desk study of the DR health sector which avoided going in cold.

We agreed with the mission to help conduct an assessment. A senior academic in the DR was selected to head the assessment team, which he recruited. We provided (Spanish speaking) consultants from the United States. The assessment looked at the health conditions, the health services and the things that had worked and had not worked in the DR health sector reform in the past.

The assessment identified a major unmet health need. There was very high infant and child mortality in the rural areas. It seemed that a rural health service focusing on immunizations, health education, and identification and referral of health emergencies in the target population of young children could do some real good and be affordable. The service could be based on community health promoters and delegated medical functions to auxiliary health workers.  Political and administrative constraints likely to be encountered were identified, and alternative measures considered to resolve them.

In preparing the USAID project documents, in cooperation with assessment team members, we developed a preliminary design for a rural health service, a preliminary plan of action, and a basic budget to cover the projected costs. The project was approved by the DR government and USAID.

Very fortunately, Dr. Amiro Perez, the very man who had led the health sector assessment and participated in the planning of the loan, was named Minister of Health as the project began. He made the development of the rural health service a priority of his administration, having fully mastered all aspects of the assessment on which it was based and its planning. He recruited his deputy on the assessment to help manage the development and administration of the rural health service.

Five years later, Dr. Perez was able to report that the mortality rate in children under the age of five years in the rural area of the Dominican Republic had been cut in half as a result of the action of the new rural health service.

Monday, February 23, 2015

A Map of Health Risks

I quote from the Washington Post article from which the map is taken:
The world map reprinted here is a reflection of more than 300,000 medical incidents which were reported in 2014 by companies to International SOS, which specializes in health care and emergency services to clients with business travelers overseas. Based on that data, a panel took into account threats of infectious disease, hygiene and sanitation, frequency of accidents and the availability and quality of the local health infrastructure to determine how risky a trip to a particular country might be.
I suspect that the map reflects the risks faced by visitors and expats in these countries and that the risks faced by native residents might be different. The risks faced by the poor are often worse than those faced by those with more resources (who can use those resources to reduce or ameliorate consequences of risks).

The article has more detailed maps that have country names included.