World Bank And Its New Adviser On Human Development Strive To Improve The Health Of Impoverished Populations

Strive To Improve The Health Of Impoverished Populations Author: Steve Sternberg The World Bank, once a stronghold of public-spirited but nonscientific economists, has over the past decade emerged as the major financier of research to improve the health of people in Third World countries. Banking on Health: Richard G.A. Feachem, World Bank senior adviser on human development, has put health at the top of the bank's agenda. Each year, the World Bank invests $2 billion for health programs in impoverished nations, $500 million more than its nearest competitor, the United States Agency for International Development, according to Richard G.A. Feachem, the bank's newly appointed senior adviser on human development. The investment reflects the bank's recognition in the late 1980s that healthy workers are central to a healthy economy. Feachem's goal-and that of his new employer-is a monumentally ambitious one: to ensure that disease does not prevent the world's poorest people from working to lift their impoverished homelands into the ranks of developed nations. Feachem, who was dean of the prestigious London School of Hygiene and Tropical Medicine until he came to the bank last May, has broad experience in a range of key public health issues. His curriculum vitae lists 148 scientific publications on such diverse-and nonmonetary-topics as "Home-based oral rehydration therapy in rural Zimbabwe" (Transactions of the Royal Society of Tropical Medicine and Hygiene, 78:102-5, 1984) and "Air pollution and mortality in Central and Eastern Europe" (European Journal of Public Health, 5:82-6, 1995). Arcane as they might sound in the boardroom of another bank, public health concerns such as these have over the years risen to the top of the World Bank's agenda for assisting developing nations and expanding the global marketplace. The World Bank, which was founded in 1944 along with the International Monetary Fund, did not always promote health as a mainstay of global prosperity. At first, it focused on finding ways to enable client nations to build housing, roads, and bridges and to expand the industrial base. Consequently, until the 1960s, the bank invested little, if anything, in health or health research. But over the last 30 years, the investment in health has grown rapidly. Major Shift: CDC's Joseph Davis notes a change in the world bank's philosophy. Joseph Davis, director of the International Health Program Office at the United States Centers for Disease Control and Prevention (CDC) in Atlanta, says this emphasis indeed marks a fundamental shift in World Bank policies. "At the beginning," Davis notes, "the World Bank not only failed to contribute very much, but many of its loans seemed to run counter to what most of us thought the best use of its money could be. For instance, the bank continued to build hospitals after most of the other players [CDC and the World Health Organization, among others] had already turned to other issues like the control of diarrheal disease and a shift to [less-expensive] outpatient services. "But within the last 10 years, World Bank policies have come to be much more in line and supportive of current public health thought. At the current time, they are the largest single supporter of public health activities in Third World countries." Central to the bank's transformation is a belief in what economists term "human capital," the contribution made by a nation's population. "The bank believes that investments in 'human capital' are crucial to sustainable growth," Feachem says. "Rapidly growing economies are committed to an investment in human capital," he adds, naming such far-flung nations as Korea, Singapore, Chile, and Germany. "These countries believe that if they have an uneducated citzenry, in poor health, they are less likely to prosper." Theories of human capital did not originate with Feachem or the World Bank. Theodore W. Schultz won a 1979 Nobel Prize in economics for his work examining the value of human capital in an economy. But Schultz's notion quickly won widespread support at the bank and among Third World nations-many of which requested assistance from the World Bank. The World Bank lends money directly to foreign governments to complete specific projects; the funds are disbursed by the borrower nations. According to Feachem, the bank's currently active portfolio totals some $8 billion in health-promotion loans, which support 170 projects in 80 countries. And since that amount meets a fraction of the global need, the development bank annually invests an additional $2 billion-about 10 percent of its total outlay of $23 billion-on health-related programs. By the year 2000, the annual total is projected to rise to $3 billion, or 15 percent of the total, Feachem says. Barry Bloom, Weinstock Professor of Microbiology and Immunology and a Howard Hughes Medical Institute investigator at Albert Einstein College of Medicine in Bronx, N.Y., notes that a small amount of money spent on public health research brings a big return. The evidence lies in life-expectancy statistics for people in emerging nations, he says. He points to World Bank statistics showing that a per-capita income of $5,000 is all that's needed to live 70 years in even the poorest countries. "With an income of $5,000 a year in 1900 you could only buy 45 years of life-and with all the money in the world in 1900 you could not increase your life expectancy beyond that," he explains. "With the same income in 1990 you can buy 70 years of life. "What [years of life] you gain has to be the product of medical science and public health in its broadest definition." Contracting out: The bank's Bernard Liese says few needy nations can do their own research. Bernard Liese, the bank's medical director, notes that very few needy nations have the capacity to perform "in-house" research. Their health ministries usually contract with public or private universities, particularly in tropical-disease-prevention programs. A Big Return: Barry Bloom of Einstein says a little money goes a long way. Some World Bank funding does find its way-albeit indirectly-into laboratories in the United States and Western Europe, Bloom says. The bank invests $3.8 million a year in the Tropical Disease Research Program, a collaboration of the bank, the United Nations Development Program, and the World Health Organization. A percentage of that money is spent in the U.S. and Western Europe in research in tropical diseases. Bloom calls the investment crucial, particularly for parasitologists. "While the amount of money is small relative to the need, they have kept this field alive," he says. "When money is tight at NIH [the National Institutes of Health], it helps." In addition, Bloom says, by making loans to countries that can then provide a higher level of medical care to their citizens, the bank creates a global demand for the products of medical research. "That leads to the possibility that American industries-pharmaceuticals, vaccines, and devices-would gain new markets." Much of the World Bank's investments yield their biggest benefits outside the laboratories-in the streets and rural regions of the world's poorest nations-by improving population control, health status, and nutrition, Bloom points out. Feachem says the bank's investments in those three areas have grown fivefold in the past six years alone. Between 1986 and 1993, the bank has lent nearly $6.7 billion to more than 100 population-control, health, and nutrition projects, according to World Bank figures. Among the bank's primary concerns are women's health-and its effect on the health and welfare of families-and control of such rapidly spreading scourges as tuberculosis and AIDS. As part of its effort to reduce the growing populations of underdeveloped nations and improve women's health, the bank has adopted the direction endorsed at the Cairo Conference on Population and Development in September 1994. The conference endorsed efforts to encourage smaller families and family planning services as part of the overall quest for comprehensive women's health care. Accomplishing these goals will require new approaches that address the specific needs of its clients. For instance, the bank has chosen to support a plan in the Philippines to use nongovernmental organizations to deliver "reproductive health services" to low-income women. One World Bank program in the urban slums of Bombay and Madras uses street theater troupes to educate women on maternal and child health and family planning. In Bombay, the use of contraceptives has increased from approximately 20 percent to 50 percent during the life of the project, according to World Bank statistics. In Madras, contraceptive use has risen from approximately 20 percent to 70 percent, the bank calculates. In health care, the bank has become the largest donor of external funding for AIDS prevention and control in the developing world. It supports 50 projects in nearly 40 nations with loans totaling almost $600 million, a figure that is certain to rise as AIDS cases continue to multiply in needy populations. The United Nations last year moved to consolidate AIDS research programs sponsored by the World Bank; the World Health Organization; and several United Nations agencies, including UNESCO, the U.N.'s Educational, Scientific, and Cultural Organization (N. Sankaran, The Scientist, Oct. 31, 1994, page 3). The bank regards poor nutrition as the source of much of the world's misery, including the rise of infectious diseases. As a result, it has invested nearly $1 billion over two decades in efforts to improve nutrition in developing nations. Project, which began in India in 1980 and continues today, was an early example of the bank's innovative efforts to move beyond a traditional reliance on large-scale feeding programs to those that will enable populations to feed themselves. The thrust of the program is to use food as medicine-supplying food where it is in short supply-and then encourage behavioral and educational change to enable poorer populations to move toward better nutrition. In India, the bank has focused on programs that aim to improve maternal health and nutrition-particularly among adolescent girls-to influence families to break the damaging "negative spiral" of undernourished mothers and prenatal malnutrition. In China, the bank has underwritten a national initiative to iodize salt to prevent iodine deficiency, a program that is expected to save 1.1 billion person-days of lost work each year. For the most part, the World Bank supplies funding and relies on such agencies as the World Health Organization, with its worldwide reach and its unique expertise, to achieve goals endorsed by each client nation. Feachem says the bank is receptive to even the most innovative programs-so long as they stand to improve the health of its client countries. "We do not carry around blueprints or prescriptions; we do not believe that one size fits all," he says. "We discuss and negotiate health projects country by country. We're involved in HIV control in Brazil; the control of eye disease in India; and malaria control in some African countries." In addition, the bank actively participates in health-reform efforts in several nations. "Health reform is a global phenomenon," Feachem comments. "In country after country, governments are trying to determine how the health sector should be financed and managed; what should be done to increase access to care for the poor, the vulnerable, and people without insurance; and how to contain costs." He cites the U.S. as a sterling example of the "failure to contain costs." Such efforts are crucial in countries seeking to make the most of scant resources. In Mexico, a World Bank program helped develop a strategy to reassess what health services should be provided to the poor to expand the scope of the limited budget available for health spending. The bank also supports health reform programs in China, Chile, Estonia, Hungary, and Costa Rica, among others. Feachem says the bank's contacts at the highest levels of government enable it to identify needed improvements and plant the seeds of change. "The World Bank," he states, "is in the fortunate position of maintaining a dialogue with key players in presidential cabinets, treasuries, and central banks. "This dialogue goes on all the time. Into that dialogue the bank is able to feed any question it wishes to pose. We are in an easy position to put issues on the table. Sometimes, when we do, the government will say yes. Or it will say, 'We don't want to turn to the bank for this.'" ultimately, he says, the decision lies with the client nation. Davis of CDC says these contacts have paid off. The World Bank has proved itself remarkably successful in "influencing national policies and programs through its loans and its policy conversations with high-level cabinet ministers-and getting economy ministers involved in conversations about health. "Surprisingly, the bank has proven itself capable of doing that while still promoting some surprisingly innovative ideas," Davis maintains. Consequently, he calls the World Bank "a very strong partner in the public health community." Steve Sternberg is a freelance science writer based in Alexandria, Va.

World Bank And Its New Adviser On Human Development Strive To Improve The Health Of Impoverished Populations

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