When Evangelical churches consider giving (they are the only churches which I have first-hand experience with), their first impulse is to maximize salvations. They want to work in places that are “unreached.” Then they look for missionary organizations to win souls. Some of them will go one step further, and support explicitly Christian organizations to serve the poor, but only so long as they do it in Christ’s name. Never would they give to a ‘secular’ charity (for how would the people hear the Gospel, or know from whence the goodness comes)?
Do not misunderstand what I am about to say. I believe in missions, and in evangelism. Of any single action, it is still, in my mind, the most valuable; it is a deed with the highest honor. But there are other parts, essential parts, of Christianity which have been eclipsed by our blind pursuit of this highest honor. Any virtue or impulse may be corrupted if it is sought at the cost of all others. As C.S. Lewis points out on the dangers of focusing purely on the love of humanity, “If you leave outjusticeyouwillfind yourself breaking agreementsand faking evidence in trials ‘for thesake of humanity,’ and become in the end a cruel and treacherous man.” So, I think, if we hyper-focus on missions and evangelism, we will become a cruel and loveless church.
One commandment of God which is almost completely ignored by us today is charity for our brethren in Christ. Paul tells us, “As we have therefore opportunity, let us do good unto all [men], especially unto them who are of the household of faith” (Gal 6:10) and the author of Hebrews reminds us, “For God [is] not unrighteous to forget your work and labour of love, which ye have shewed toward his name, in that ye have ministered to the saints, and do minister” (Hbr 6:10).
We do a mediocre job locally with the poor in general with food drives and homeless shelters. But we do an appalling job of providing for poor brethren abroad. We know generally about poverty and how we are to provide for the poor. But we forget that we have a special obligation to poor Christians.
But who takes collections for poor believers today? How high a priority in the modern Church are poor abroad? We often see poverty work only as a means to the end of evangelism. How many church dollars go to some few thousands of pagans in the Pacific Islands, while millions of our brothers starve in Africa? We send missionaries to the “10/40 window” because there are few Christians there. But how many of us really care about the plight of our brothers in that same window? How many sermons are preached on the plight of the brethren in that window? I have not heard one. We are letting our brothers starve so that we can first win new converts. This ought not be so. We ought to first take care of our own family , and then seek to serve others.
And were we not commanded to? Who are the sheep in Jesus’ Matthew 25 parable? Was it those who were powerful missionaries? Were the goats sent to hell for their lack of evangelism? No. It was for a lack of charity to “the least of these my brethren” (Mat 25:40). Those who saw Christ’s brethren in prison or naked or hungry and did nothing were sent to hell. And who are Christ’s brethren? He tells us: “he stretched forth his hand toward his disciples, and said, Behold my mother and my brethren!” (Mat 12:49).
And where are the least? Where are the hungry, poor, imprisoned Christians? They are in the developing world. The centroid of Christianity is moving back again to the south and east, where there is still terrible poverty, disease and death. There is again a need amongst our brethren to the south and east. It is not now in Jerusalem, but in Africa and Asia.
Remember also Paul’s warning, “But if any provide not for his own, and specially for those of his own house, he hath denied the faith, and is worse than an infidel” (1 Ti 5:8). John also questions the faith of those who fail this duty, “But whoso hath this world's good, and seeth his brother have need, and shutteth up his bowels [of compassion] from him, how dwelleth the love of God in him?” (1Jo 3:17). We Evangelicals struggle with hypocrisy, with doctrine, with patience and lust. But there is no place where we are closer to hell than in our apathy about the poverty of our brothers abroad.
We care more for the material condition of the unsaved than our own family. After coming to Kenya, I’ve often been asked about the missionary opportunities and never about the poor condition of the brethren. And I was not offered help to relieve their condition, but instead, Bibles. Bibles are good in themselves, and so are missions. But the fact that the condition of our brothers in Kenya is not even thought of is damning. In the present and manifest distress, the fact that church global missions budgets are often an hundredfold higher than global poverty budgets is damning. We must repent.
Providing for our own family is of utmost concern. Of what other duty which if we neglect it, are we promised hell (Mat 25:46), called worse than infidels (1Ti 5:8), said we abide in death (1Jo 3:14) or asked how the love of God could abide in us (1Jo 3:18)? What other duty was so important to distract Paul, the missionary’s missionary, from missions (Rom 15:26, 1Cr 16:3, 2Cr 8:2)?
But consider the wonderful opportunity God has arranged for us. For where we are poor, our brothers are rich; and where we are rich, they are poor. We should remember: we in the West were made rich in money but poor in spirit. Consider the power of the Holy Spirit, spreading Christianity like a wildfire across China, India and the rest of the developed world. Missionaries, evangelists and prophets are being raised up in multitudes by the Spirit there. And what of us in the West? Though we have a heritage rich in Missions and Evangelism in the First and Second Great Awakenings, now it seems to be God’s will that the fire be cooled.
But in the place of that fiery passion, God has blessed us instead with the riches of this world. We are the most productive people ever to have lived. We are far richer than the Romans, the Babylonians, the Greeks, the Arabs, the Byzantines and the Britons. We have money, business, ingenuity, organization and technology. We are better equipped than any other people in the history of the world to end the desperation of poverty, an affliction persistent since the Fall of Man. We are the first generation in the history of the world with the ability to actually do it.
Missions is a higher calling indeed (1Cr 12:28), but not one that we are particularly good at. I came to Kenya thinking there was some opportunity for missions. I soon realized that I had exchanged an excellent mission field for a poor one. Though God has given me gifts in evangelism, there were fewer opportunities in a rural village in Kenya than in the ivy halls of Stanford. Christianity is stronger in Kenya than it is anywhere I have seen in the US, and I found myself especially ill-equipped to evangelize, particularly when compared to my fiery brothers here.
While not given particular gifts in evangelism, we as a culture have powerful and unprecedented gifts in “healings, helps, governments” (1Co 12:28); let us use these to their utmost, while ever coveting the greater gifts of our brothers in the developing world. We have a greater ability to give than any people at any other time in the history of the world. One in our middle class has a greater ability to give than even kings and merchants of old. So let us give in abundance and “with simplicity” (Rom 12:8).
And let us never forget the other edge of the sword of opportunity; it cuts both ways. “For unto whomsoever much is given, of him shall be much required” (Luke 12:48). We will not be held guiltless if we squander the greatest opportunity for generosity in the history of the world. And we will surely draw close to hell if we close our hearts to our brothers.
Let this generation of Evangelicals be remembered as our great forbears in Britain were. Two centuries ago, William Wilberforce and his fellows ended the slave trade in Britain and will be forever remembered for it, both on earth and in heaven. Let Evangelicals of this generation be remembered not as those whose greedy hearts were cold, but as those who set the captives of poverty free, those who brought food and shelter forever to billions. Let us act like the Philadelphians, the city of love for the brethren, a Church that keeps God’s word to provide for our Christian brothers and for the poor. And then we can receive Christ’ promise, “Him that overcometh will I make a pillar in the temple of my God, and he shall go no more out: and I will write upon him the name of my God, and the name of the city of my God, [which is] new Jerusalem, which cometh down out of heaven from my God: and [I will write upon him] my new name” (Rev 3:12).
We are not saved by works alone. But the Kingdom is not built by faith alone. And it is not only built by Christians. Certainly God uses all for his purposes. Even Satan himself will serve God’s purpose, as will his instruments like the Pharaoh of Exodus; even vessels for destruction have their place in the Kingdom (Rom 9:22).
There are many men who have seen God, whose work will survive them. The mathematician who sees beautiful Truths of God but fails to worship Him will indeed pass away. His postulates will not. And there are many men who love God, but whose work is headed for destruction. The Christian who builds a corporation which oppresses the poor may reach heaven, but as one escaping a fire (1 Cor 3:15).
Truly, we are commanded to use “mammon of unrighteousness” to achieve God’s ends (Luke 16:9). I once heard a missionary speaking on medical missions, encouraging the use of secular grants over church donations, “Why use God’s money for what Satan will pay for?”And if we are to use the fuel of the Enemy, why not also his vehicles? Would not Christ also commend us for our shrewdness in that regard?
This is war. Our mission: to bring about the Kingdom in every way to every place. And if Poverty is one foe standing in our way, can we not coordinate our efforts with its fellow foes? If Poverty is entrenched in a non-Chrisitan region, call it Sodom, can we not support those fighting it, whatever their alignment? Even if this does nothing to fight another of our enemies, Faithlessness, does this not advance the cause of Christ nonetheless?
But it is doubtful to me that these Enemies of the Kingdom are not aligned and strengthened by one another. Let us return to Sodom. Its citizens have never seen compassion before, but the coming of a secular organization shows it to them. Will they not be drawn to know from whence that compassion comes? And will not their inability to answer (for few secular people have any idea why they do good) create an intense yearning for Truth? Would not this Secular compassion till the spiritual soil of Sodom, allowing missionaries to sow where they had not tilled?
Does not “every good gift…[come] down from the Father of lights” (Jam 1:17)? Does compassion have any other source but Christ? And if it is from Christ, will not even secular compassion “draw all men unto” to its source (Jhn 12:32)?
But even assuming we could know that Sodom would never repent, would fighting Poverty there be in vain? I think not. All of Christ’s charity failed to win converts, for by the end of his ministry, “all forsook him, and fled” (Mark 14:50). I would think it blasphemy to call any work of God futile. I think His charity will live on eternally even if its objects do not. Of course, it is the greatest thing for both to live on. But the hard-hearted cannot sabotage the reward of the charitable. There is some element of the charity itself which must be eternal.
Is it wise for Christians to draw such a hard line in their giving? I think not. I think we shall be rebuked for a lack of shrewdness if we continue along our present course. When effective organizations who serve the poor better than Christian ones are ignored for their secularism, will we not be judged for the poor who went hungry because of our foolishness? We should aim to serve the poor by the best means presented to us.
We should remember that arrows into the heart of Poverty are no less lethal because they are shot by a secular bow. And if a secular bowman has the shot, should we deny him arrows?
I was considering the best way to define poverty, and I think I may have stumbled across a very old idea that might fit the bill:
“ …all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”
Perhaps “poverty” is when you lack life, liberty or the ability to pursue happiness?
Poverty can certainly limit these human rights. Life can be limited by starvation the same as it can be provided by an invading nation or a murderer. The government has a commission to prevent the violation of the right in the case of the latter, but which it is the job of the government to prevent.
The lack of liberty can come in many forms. It may not just be liberty in the sense of suffrage, but also in terms of education and beliefs about your own capacity. A slave working on a plantation certainly lacks liberty, but so does a factory worker who cannot leave his situation or promise a better one to his children. Likewise, a person with the ability to better his situation may have been convinced that he is unable, and perception becomes reality.
Limitations of liberty
If a person wants to run a marathon, three things can limit her. The first and most obvious is physical ability; can the person’s legs last for 26.2 miles? Secondly, does a physically capable person believe she can run the distance? And finally, is she willing to do it? She needs physical ability, belief in her ability, and wiliness to actually run. If any one of these things is lacking, she will not be able to complete a marathon. Her freedom is to run a marathon is limited by her body, her mind and her spirit.
The same is true of a poor person. A person may not have liberty or the ability to pursue happiness because they are physically unable (they lack the food to survive), mentally unable (they do not know or believe they can advance), or spiritually unable (they are unwilling to better their situation). To truly have liberty, all three kinds of barriers must be removed.
Most poverty work centers around the first one. We boost income, and build clinics. Most people believe that’s all there is to poverty. But, if liberty is the concern, then simply addressing physical barriers is insufficient.
There are many places with an overbuilt medical infrastructure; physical barriers are reduced. But the buildings remain empty. Mothers still birth their children at home and rarely use the clinic. In many of these places, they know that they’re supposed to give birth in a hospital and that it’s safer. But they prefer their homes. They have every physical and mental barrier removed; some simply lack the willingness.
Mental barriers are also sometimes addressed in development work. And even those who do trainings to address mental shortcomings will not be fully successful if they stop simply at information transfer.
Do we stop because it’s hard? Or because we’d have to address a culture and a preference (both of which are off-limits to relativists)? Changing minds like this is really really hard. But it’s what pastors, motivational speakers and advertising executives make a living doing: affecting people’s willingness to do things. Some of their job is removing physical or mental barriers; but most of it is giving people a spirit or desire to do a certain thing. And we cannot forget this very important piece of liberty.
Pursuit of Happiness
The ability to pursue happiness is a beautiful thing. It is not a guarantee of happiness itself. It is not the ability to hold property (Locke’s version). It is the abstract idea that one can seek happiness in whatever way one wants. Nobody can provide or force someone to be happy; the farthest one can go is to give another the ability to pursue happiness. This is a particularly hard place to stop, but a critical one. We can give liberty and freedom, but we cannot in the next moment take it away to force what we think will bring happiness. Happiness cannot be coerced. People must be truly free to choose misery, and we must not stop them, for to do so would be to undermine liberty and subverting the deeper happiness it brings.
We can build clinics, teach mothers about them, and advertise them. We can work with chiefs and elders to open their minds to the benefits of clinic birth. We can remove economic, social, and cultural barriers. But if a woman still chooses to give birth at home, we must let her.
Freedom and Its Spread
Freedom is not just government type; it’s not just being able to vote. It’s the ability to make choices and to live a full life. It’s climbing upward and giving your children a better situation you had. There are still billions lacking the promise our Founding Fathers sought to give to us.
But how does the flame of freedom spread beyond the shores of the United States? It’s no longer as simple as throwing off a single oppressive king with an eloquent letter. The oppressors are more than political, and so the solutions must be also; the answer is no longer simply in government or a good constitution.
The poor need a Declaration of Independence. They wouldn’t be throwing off an oppressive government, but an oppressive system. Parts of that system are sentient and malicious (dictators, oppressive companies) and parts of it are non-sentient (viruses, climate). And just as the Declaration of Independence wasn’t itself a new system, it made it clear that one would soon be necessary. The War of Independence that must inevitably follow will be fought on the soil of many foreign nations.
I pray that I may fight as their ally.
The Challenge of Liberty Poverty
The challenge with this definition is that it is the most difficult to quantify. It is the most abstract (which, if you believe Plato, means it’s potentially closer to truth than the less abstract ones). Donors don’t want abstract concepts. They, increasingly, want numbers. But this can be our ideal, the thing we really have in mind when we enter a community and want to help. It’s not about money, or property, or even improving conditions. It’s about Liberty.
A dollar spent in the US buys orders of magnitude less health than one spent abroad. It turns out that for most questions, the equitable and the efficient are often the same. Kenya has a lower life expectancy and a lower GDP (it’s more equitable) AND a dollar spent there will save so many more Disability Adjusted Life Years (DALYs[3]) than a dollar spent in Japan. So to a first order approximation, this ethical dilemma is only theoretical.
As a second consideration which must be addressed before the question directly. Serving the poorest has more broad-reaching effects than simply an increase in DALYs (which is usually optimized in cost effectiveness analysis or CEA). An intervention that allows a poor person to escape poverty had long-reaching effects on that person, their children and their society. Saving a man from premature death by AIDS does more than help him, it allows him to contribute to his community. Getting people onto the proverbial ladder of development, putting them in a position where they could begin to climb up and improve their situation, is an important consideration beyond strict CEA.
Nevertheless, there are times and places where you can help people more effectively who are better off, or you can less effectively those who are worse off. All other things being equal (particularly the Development value discussed above), I value efficiency over equity.
There is certainly an argument to be made for serving the poor. You have to try really hard to find a philosopher or religious teacher who teaches against this (perhaps Ayn Rand, but I think even she may see the value of Global Health as a piece of International Development). To most (including myself), it seems to be a Good which is self-evident. But in much of global health, everybody’s poor. If I could bring 10 years of added life to 1000 people making $2/day or to 500 people making $1/day, I’d choose to help the richer and so save more people.
As I’ve written elsewhere[1], where Kantian ethical statements are satisfied, (i.e. One ought to help the poor), Utilitarian ones should pervade (“Greatest good for the greatest many”). I disagree with the argument that is made that achieving ultimate equality in income is a moral imperative (this argument is frequently attributed to John Rawls, though I admit I’ve only had secondary exposure to him). I reject a morality whose end is the homogenization of income; I disagree that the lack of equality (e.g. Capitalism) is inherently bad, and I do not think that the logical end of this, Communism, is even a good place to be (see Harrison Bergeron[2]). I fail to see equity as an independent axis of the Good; it certainly correlates to the Good. Often those who are poorest are most oppressed. Those who are weak are enslaved. So I agree that injustice is committed against the poor, but as we all know, correlation is not causation. The badness is in the injustice, not the disequilibrium of money.
Truly it is moral to serve the poor for reasons of mercy and compassion. Suffering is indeed evil that should be fought against. But I cannot see a universal moral reason why some people can’t drive Hondas and others Acuras.
Fortunately, this theoretical situation is not that big a problem. It’s clearly moral to help the poor. And the poorest and the easiest to help are often the same people. When they’re not, most of those remaining could be helped in escaping povery by Global Health. When they can’t be, we should consider showing the greatest good that we are capable of. We can discuss these minor points of philosophy (and really should), but it’s not where we, as a society, are failing. I hope that one day we’re having this very debate broadly: “Should we save the really really poor? Or just the really poor?” Unfortunately, we’re still at the, “Should I buy a third car? Or a new TV?” phase.
[2] One of my favorite short stories and a powerful argument against the ethics of Equality. It opens thus, “THE YEAR WAS 2081, and everybody was finally equal. They weren’t only equal before God and the law. They were equal every which way.” Vonnogut, Kurt. “Harrison Bergeron.” 1961. http://instruct.westvalley.edu/lafave/hb.html
“Why Helping Working People Keep Working Is Really Important” · The costs of missing work for treatment and because of illness should be considered.
· Pneumonia sucks and worsens life by 27.9%.
· It is important to have the right perspective in addressing health problems and if our goal is development, we should approach problems with the good of the whole community in mind.
· Doing an analysis from a societal perspective suggests that we should prioritize working adults in pneumonia treatment.
Note: This also is technical. Sorry to my non-nerd readers if you do not find this interesting.
The following thought just occurred to me in thinking about my previous article: opportunity cost has been ignored. When we normally think about the ‘cost’ we think about it in terms of dollars spent on treatment, and the ‘benefit’ as being years of quality life lived[1]. In my own analysis, I didn’t discuss the difference in opportunity cost. This will be especially important to development.
If we want a society to develop, a large part of that must be in improving income generation. Any health care analysis cannot ignore the impact it is having on the ability of people to generate income. Ultimately ‘sustainable’ means that people can earn enough money themselves to not need outsiders.
Pneumonia Sucks [9]
So let’s return to our question. Pneumonia (my new favorite developing world illness) has some pretty serious complications. The World Health Organization rates diseases based on how much they suck[2]. And pneumonia sucks pretty hard. The DALY weight is 0.279[3], putting it equal to having an amputated arm or being deaf over the period that you have pneumonia. Another way to put this is that it’s better to live three years without pneumonia than four years with it. That’s how bad it sucks.
The burden of disease (roughly “how bad it sucks”) is not the same thing as the cost. It is essential to determine who is spending the money when considering in the cost. In my previous analysis, I was incorrectly considering the patient perspective.
In my previous (conceptual) analysis, I ignored the cost of visiting the doctor and loss of productivity at work. This will be a huge driver of the overall cost, particularly when considering disease in working-age adults. Not being able to breathe sucks for a child, but it doesn’t affect as directly the income generation of the family. And this is a critical consideration in development. Health, at least at this stage of development, should be a means to the end of self-sufficiency. Time is extremely valuable, especially when a person’s time is worth $1 a day.
Simplified, Make-Believe Analysis
Warning: Math approaching. For those who have had severe allergic reactions to math in the past, it is recommended that you skip to the “Discussion” section. But it shouldn’t be all that bad. There's nothing but the four basic operations[11].
Let’s get back to pneumonia. Imagine Abasi, a 30 year old Kenyan man with a wife and a 5 year old daughter named Sakina, coming down with pneumonia. He’s sick and he’ll stay sick until he gets treatment which costs $4.00 (and we’ll assume that it’s perfectly effective). Abasi will die five years after getting pneumonia if it remains untreated. Let’s also say that he’s only able to work at 75% capacity because of his difficulty breathing. The clinic is far away, so it takes a full day to walk to the clinic, get treatment and walk home. In that day, he loses $1.00 worth of productivity. But every day, he’s losing $0.25 because he can’t work. Healthy, Abasi can look forward to 33 more years[4]. Sick, he only has 5 (and that with a lowered productivity). The ICER can be calculated as follows:
This means it is cost-saving. In the long-run, Abasi saves money by getting treatment. This is superb. In a sense, it is literally an investment ($5 initial investment to save $312 which is a 6200% increase in 5 years; that’s what I call an ROI).
If the analysis were repeated from the perspective normally taken (the “provider” perspective), it comes out costing money. Repeating the analysis above from a provider perspective (ignoring ignoring the value of Abasi’s time and lost wages), it comes out to costing $0.14/DALY.
Now imagine his daughter, Sakina, comes down with pneumonia. She should be able to look forward to 56 more years of life and has the same five years to live if she doesn’t get treatment[4]. The difference here is that she doesn’t help generate income for Abasi, so the major economic impact on Abasi drops out of the equation. He still has to take the day to travel to the doctor, pay the same amount for the medication, and (for the sake of this simplified analysis[5]) have the same discounted DALYs. From Abasi’s perspective, the ICER for his daughter is:
Note that this is now positive; when Abasi spends money to save his daughter, it is not cost-saving. Nevertheless, if Abasi values a year of his daughter’s life at something more than $0.10, he should buy the medications. The provider perspective (which doesn’t care that Abasi took a day to travel) is $0.08/DALY.
One more exercise. Imagine we took the societal perspective, concerning ourselves with the overall wellbeing and costs to society. And imagine we were concerned about only a five-year window rather than the lifetime of Abasi and Sakina. With smaller windows, long-term goods are washed out, but it’s a conservative assumption that is verifiable. Would this be cost effective for Abasi’s pneumonia? Sakina’s? Repeating the analysis from a 5-year societal perspective shows that it is cost-saving for Abasi and cost-effective for Sakina ($3.57/DALY) [7].
Perspective
Abasi
Sakina
Payer
Cost saving
$0.10
Provider
$0.14
$0.08
5-year Societal[10]
Cost saving
$3.57
So as you can see, the only perspective where treatment of Sakina is more cost-effective is in the provider perspective. Which helps explain why we are so concerned about saving the children: from our perspective (that is, one only concerned with health and not development), it’s a better idea to treat kids before adults. But if you are Abasi, or if you care about the immediate development of the society he lives in, then you ought to prioritize him.
Discussion
What’s my point? First, these numbers should wake us up: 8 cents for a year of healthy life[8]. I don’t bother to stop and pick dimes up off the street. And yet it is for want of this that people like Sakina are dying[6].
Secondly, these numbers should be translated from Imagination Land to reality. I made all this up out of thin air. I think in this easy case (pneumonia treatment), I’m probably right in recommending emphasis on treatment of Abasi. But there are many questions which are not so easy. Most treatments are not extremely cheap, extremely effective and most diseases do not have the morbidity profile of Pneumonia. Even in Pneumonia, if treatment was not close to 100% effective as I assumed, or if there were significant side effects, or the costs were more than $4.00 (which is certainly possible), these conclusions do not stand. Most work in this area is either not applicable; treatment costs and regiments in the developed world are perfectly irrelevant to the developing world. It would be quite useful to compare the cost effectiveness of various developing world interventions from a societal perspective, side-by-side, using local prices. If such a model were constructed well, the details could be adjusted (i.e. Penicillin here costs $3 instead of $1.50 in Kenya) and the conclusions, recalculated.
Finally, it is very important to consider our perspective and our goal. If we don’t care about development and our goal is simply to extend life, then paying for Sakina is the best idea. But if we are concerned about the societal costs, more emphasis should be placed on Abasi; his pneumonia will cost society more than Sakinas in the short term. If we are concerned about development, we cannot just look at saving Sakina. She is truly the future of Kenya, but Abasi is the present. And it is he who must build the future. He must have an income to support Sakina, pay for her school, and tear off the shackles of poverty. And health interventions ought to aid him.
Conclusion
This analysis shows that it is extremely important to care for those who are the ones developing. Mercy compels us to care first for Sakina; prudence reminds us to care for Abasi first. It is the same thing that they tell you on airplane safety videos. While mercy compels us to put the oxygen mask on our children first, prudence (and the video) reminds us to put it on ourselves first so that we can be able to help our children. Let it be so in Kenya.
If our goal is five-year development, the healthcare should focus on Abasi. But I pray to God that we can find the eight cents to save Sakina.
Notes
[1] I’m sure this thought has occurred to someone; it may actually be taken into account in the calculation of DALYs. In a brief review of DALY definition (Drummond, et al “Methods for the Economic Evaluation of Health Care Programmes” Third Ed. p 187), it did not seem to include lost wages. I’m fairly sure that ‘cost’ of lost work should be counted separately. This does need outside confirmation, however as I’m not certain.
[2] http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_part3.pdf
[3] I have found this table at long last! WHO did not make it easy. http://www.who.int/healthinfo/global_burden_disease/GBD2004_DisabilityWeights.pdf
[4] Life Tables, Kenya. http://www.who.int/whosis/database/life_tables/life_tables.cfm
[5] As another simplifying assumption, I assumed 0% discounting.
[6] To cover my bases, we can’t just spend $0.14 cents and save someone practically. Health and social systems have conspired against their getting healthy.
[7] The actual numbers are -$219.64/DALY for Abasi and $3.57/QALY for Sakina. The interpretation of the larger magnitude Abasi number is confusing so wasn’t displayed in the text; this sort of analysis isn’t usually used to evaluate methods of saving money. The most important feature is that it is negative.
[8] When I say ‘we’, I mean the developed world. We’re usually in the perspective of the NGO provider.
[9] I have looked for data like I present here many but to no avail. I am very happy about finding it.
[10] Why did I not calculate the 25 year societal perspective? Because I’m fairly sure I need to learn how to discount money (I’ve forgotten how to properly do this) to answer the question even close to correctly. Also I do not know how to compare negative ICERs. Maybe I could model it like an investment?
[11] And if you're really nerdy, you could snicker that there is never more than some combination of the four basic operations. After all, what is integration but an infinite number of additions?
Health plans designed for the poor (“Appropriate Healthcare”) should be cheap, accessible and should address the major causes of morbidity and mortality.
The top seven health problems in Kenya, making up more than 65% of the mortality, are malaria, lower respiratory infections (e.g. pneumonia), HIV, prenatal problems, nutrition, TB, diarrheal disease.
Cost effectiveness is a helpful way to think about allocating healthcare when resources are limited, particularly in the developing world.
Health fairs and local health workers could be two ways to address these major health issues in a cost-effective manner.
An appropriate Kenyan health plan should focus on the most cost-effective ways to address the seven major Kenyan health problems.
Note: this is far too long (and probably too technical) for a blog. I apologize in advance to my normal reader.
Introduction
“Health Insurance” as it is modernly conceived serves two major functions. Firstly, as the name implies, to insure that you’re taken care of if something really bad happens. The more recent (and perhaps important) part is health maintenance. Health insurance pays for annual checkups, screening exams, and (increasingly) over the counter meds like allergy meds. So it’s not really health insurance. And this is what the public health people love: prevention. In the developed world, these two things are bundled together because we’re really rich and don’t really care. We need ‘em both, so why bother paying for health maintenance and health insurance separately? This is likely why no market for stand-alone health maintenance programs has emerged. Also, the kinds of death we want to afford when we buy health insurance require expensive hospitalizations, chemotherapy, and bypass surgeries. So, because these things are ridiculously expensive, so is the whole package of American “Health Insurance.”
But when we think about appropriate goods and services, which I’ll define as, “goods and services useful and affordable to poor people,” we need to think about economy. While we cannot forget that people in the developing world are dying of cancer and heart disease, traditional Coronary Artery Bypass Grafts aren’t even close to appropriate for those earning a dollar a day. If we were picking apples from a tree, we shouldn’t have a “Top branch or bust” strategy. There is plenty of fruit that we can reach while we’re still on the ground.
There are things people are dying and suffering from (we cannot forget what is called ‘morbidity’ in our consideration; that is, suffering short of death) which are easily prevented and cured. We want to take care of the easy stuff first.
If a healthcare plan were to be designed for the poor, it would have to meet these criteria
· It must be cheap, cheap, cheap
· It must be accessible
· It must addresses major causes of mortality and morbidity
We want to avoid the hospital. That’s where things get really expensive. In fact, we want to avoid the clinic if it’s at all possible. And transportation. And waiting. And we need to make sure we pay for the important stuff. We need to beware good intentions: we do not want a comprehensive plan covering everything but nobody.
Kenyan Problems
In considering this question, I’m going to look at some data from Kenya (believe it or not, “Africa” isn’t a country). Here’s some data from the World Health Organization from Kenya on the top five causes of overall mortality (compiled in 2002).[6]
Condition
Mortality (thousands)
%
#1 HIV/AIDS
144
38
#2 Lower respiratory infections
37
10
#3 Diarrheal diseases
24
7
#4 Tuberculosis
19
5
#5 Malaria
18
5
Cost EffectivenessAnalysis
The cost effectiveness analysis perspective will be very useful here. It contradicts the (probably true) belief that human life is invaluable and says essentially, “The reality is that we have limited resources; how can we do the greatest good with them?” Here’s a super-simplified example.
You go to the doctor and the doctor, after running some tests, comes in and tells you, “I have some good news and some bad news. The bad news is you have Really Deadly Disease (RDD) which, if untreated, will kill you tomorrow.”
You, having nerves of steel, are cool and collected. You ask flatly, “What’s the good news?”
“The good news is that there’s a cure! Well, it’s not really a cure. It’s a drug you have to take for the rest of your life. As long as you take it, you’ll be healthy. The day you stop taking it, you’ll die. And the drug costs $45,000 per year.”
In this example, someone (your insurance, hopefully) has to pay $45,000 for every year of life you enjoy. This is usually adjusted for quality and so we usually say Quality Adjusted Life Years or QALYs (you would discount life lived in a sub-optimal state; you might count 1 year as a paraplegic as 0.5 QALYs). Compared to the alternative (instant death, which costs nothing), you have an incremental cost of effectiveness of $45,000/QALY. That is something we can pay in the developed world, and because of such expensive treatments, is why our health insurance costs what it does.
QALYs and Development
In thinking about the developing world, we have extremely limited resources. We’re not talking about whether the line should be at $45,000 or $46,000/QALY. This kind of analysis has a much more powerful impact on developing countries. If a health-minded NGO wanted to do an intervention, are anti-malarial bed nets, antibiotics, or AIDS treatments more cost effective? Can more life be saved with one over the other?
In Kenya, healthcare spending is $105 per capita in 2006 (by PPP, not by exchange rate). Only a fraction of that has been by the government: $586 million (2% of $29.3 billion GDP) [1]. So even assuming we have $105 to work with (it’s very likely that most of that is a lot of spending by the richest in Kenya), what is more cost effective? Treating Malaria or Malaria bed nets? And whatever of those is better, is that more cost effective than treating HIV? And is HIV treatment better than antibiotics for pneumonia?
If I was an NGO who had $1 million and I wanted to do handouts, what should I spend money on? Should I fight AIDS and invest in HAART (Highly Active Anti Retroviral Therapy)? Or should I buy ITNs (Incecticide Treated Nets)? For HAART, it’s $1000 to save a life year[3]; for ITN, it’s $86. In other words, I could save over 11,000 people from Malaria for a year (assuming $4/net I’d have to buy 250,000 nets to do this), or I could save 1,000 people from HIV for a year. Of course there’s more people suffering from HIV, but with limited resources (as all NGOs have), the focus should probably be on addressing Malaria first. But then again, vaccinations against Pneumonia (Hib) are even more cost-effective ($62/year saved). And what about treatment for Pneumonia?
This is the sort of analysis which must be done as this work progresses. Any fool can shout about how big a problem is. It takes a wise man to find a solution. This is the mindset with which the remainder of this paper was written. Though there is not the data to do a numerical analysis, the things which have been chosen are gross approximations of what may be actually cost-effective.
An Overlooked Problem (A Ripe and Low-Hanging Fruit)
Why haven’t we ever heard about the #2 killer in Kenya (and from what I’ve heard, much of Africa)? We hear about AIDS all the time. And diarrheal disease all the time. And TB and Malaria. But why don’t people talk about “Lower respiratory infections”? And yet according to Kenya’s Ministry of Health, 1 in 37 Kenyans goes to a clinic for Pneumonia each year [9].
Here’s the ironic thing: they’re the easiest one on that list to treat. Everything else (with the possible exception of diarrheal disease) requires rather extensive measures. But Lower Respiratory Infections (aka “pneumonias”[8]) are usually easy to diagnose and easy to treat (certainly by comparison). X-rays are nice, but they’re usually just to confirm what the doctor can find out from getting a good history and physical. Stethoscopes aren’t that expensive[7]. And neither is first-line pneumonia treatment: Amoxicillin w/ clavulanate (“Augmentin”) [5] which can be gotten for $1.34 in Kenya[4].
That’s what you call affordable. For someone living on $1 a day, a $4 ITN with long-term (but no short term) benefits is a hard sale. A $1.34 drug which lets a person get back to work/play/school/home in a few days is a much easier sell. But there is presently no cheap way to get at it without spending a day to go to the clinic, paying for transport, waiting for a doctor, paying for the visit, get diagnosed and then hope they have the medication you need. The out of pocket cost is too high, not to mention the opportunity cost (instead of earning money, time was spent going to the doctor).
Idea One – Local Health Workers
How do we make it easier to treat pneumonia? Train local health care workers. Buy them stethoscopes (or loan them the money for stethoscopes and let them pay them off by working) and let them sell their services to their neighbors. It would be their job to purchase a small amount of pharmaceuticals and sell them to those who need them. If disease tracking was a concern of the local dispensary, they could require the worker document each case and only sell a new batch of drugs with the delivery of patient records. The patient form could require a signature and include the price of the drug (to limit health worker corruption), and describe the level of training of the worker. Or if we really want to be fancy, we could use SMS to communicate in real time to the dispensary.
The bottom line is that a person with pneumonia for, say, $0.25 can get a diagnosis and accordingly be offered treatment: “Yes, this is Pneumonia; I’ll sell you the drug for $1.32” or “No, this is not Pneumonia; I won’t sell you the drug.” This would provide broad and easy access to pneumonia treatment, and reduce mortality and morbidity of the #2 killer in Kenya, in addition to providing supplemental income for the health care workers.
Idea Two – Health Fairs
As transportation seems to be a major issue, bring the clinic to the people. This is what well-intentioned white doctors do all the time, and are able to help hundreds or thousands of people on a single day.
The organizers would stock up on common meds (“common” will quickly be defined after the first of these; likely antibiotics, de-worming meds and vitamins; it may be a good thing to do community surveys about before the first one). Ideally, doctors and nurses would volunteer or already be paid (by the national government); if not, their daily wage would be a part of the cost. Para-medical personnel (health representatives) would act as medical students under the doctors present, learning what they could (so as to better help people between fairs) and aiding in the streamlining of patients. Other volunteers would be needed for paperwork, administration and set up. Also, this should be done on a weekend or holiday where the opportunity cost would be lower (people don’t have to miss work/farming).
It could be discounted or (more likely) free for those on the healthcare plan; a fee would be charged for those who aren’t (reasonable, of course). All health related business could take place on a single day. Nets could be retreated. Sick people could get their meds (or at least people sick from diarrheal disease and pneumonia). Children could learn hygiene. In addition, with good record-keeping, this could be an excellent venue for tracking health statistics (a pre-interview could record recent births, deaths and illnesses in their family, relatives, friends, neighbors). These fairs could be rotating and occur as often as there was demand and funding.
Conclusion
Imagine we had a health plan which addressed the seven strategic Kenyan areas (HIV, Lower Respiratory Infection, Malaria, TB, Diarrheal disease, Neonatal/Maternal health, and Nutrition). For the expensive and well-funded diseases, it would act as a referral network, perhaps providing transportation to well-funded HIV centers. It would cover treatment by local health workers or health fairs for simple pneumonia and diarrheal disease, in addition to some simple nutritional supplementation if anemia is suspected. It would provide annual insecticide for bed nets. It would pay for a trained birth attendant. And it would pay a certain amount for emergency transport for serious illness.
By focusing on the extremely cost-effective interventions and omitting the more drastic ones (direct treatment of HIV, paying for hospitalization), healthcare may become affordable to even the poorest[13]. Much change would be necessary before this could be realized. It is certainly not possible with the present system. But it may become possible with a few intelligent changes and a community to support it.
The Challenge: To design a healthcare plan that would prevent and treat the most deadly and painful diseases accessibly and affordably; to drastically reduce the morbidity and mortality of the rural poor with $1.00 per month per person[10].
Notes
[1]Stats taken from GapMinder (which draws from reliable sources like the World Bank) http://spreadsheets.google.com/pub?key=pk7kRzzfckbzz4AmH_e3DNA&gid=3
http://spreadsheets.google.com/pub?key=phAwcNAVuyj0XOoBL_n5tAQ
[3] Technically this particular study used Disability Adjusted Life Years (DALY); it’s similar to a QALY but figured out with a slightly different method. Fundamentally it’s saying the same thing.
[4] http://www.kemsa.co.ke/datagrids/kemsa_commodity_catalogue.php Item - PHA0545. 105.25 Kenyan Shillings which, according to Google, becomes $1.34 as of 5/2/09.
[5] 96% of pneumonia should be sensitive to this treatment in the US; it may even be higher in Africa because of less antibiotic usage. Taken from “Diagnosis and Treatment of Community-Acquired Pneumonia” by the American Academy of Family Physicians. M. NAWAL LUTFIYYA, PH.D., ERIC HENLEY, M.D., M.P.H., and LINDA F. CHANG, PHARM.D., M.P.H., B.C.P.S. http://www.aafp.org/afp/20060201/442.html
[6] http://www.who.int/whosis/mort/profiles/mort_afro_ken_kenya.pdf . It is very interesting to note that in Kenya’s Ministry of Health annual report, they came to different conclusions. They talked about morbidity in the executive summary and said #1 was Malaria and #2 was respiratory infection. It seems they’re making their conclusions based on who shows up to the hospitals. If I’m right about the data source, this discrepancy probably means that HIV patients aren’t showing up to governmental healthcare facilities. Perhaps they don’t have the money for treatment. Perhaps there stigma. Perhaps they’re going to NGO sites who don’t communicate with the government. In any case, it’s a problem. Beware: it’s terribly written and goes on for a page of the Executive Summary complaining about how bad the data is and why it was that bad. For that report, check out: http://www.health.go.ke/Healthfacilities/Annual%20Report%20_%20HMIS.pdf
[7] I remember buying decent quality stethoscopes for my group at $30 each; they get down to $7 on the internet… not that I’d trust a $7 stethoscope.
[8] Looking at the MOH report, they seem to think “Pneumonia” and “Respiratory Disease” are two separate things (some of the charts inconsistently call it “Other Disease of the Reparatory System”… I’m assuming ‘other’ than Pneumonia). Maybe in Kenya, they call typical pneumonia “pneumonia” and atypical pneumonia “other disease of the respiratory system.” Without ever defining their terms, it is impossible for me to know what “Respiratory Disease” means, or what possibly could be hospitalizing hundreds of thousands of Kenyans that is not COPD or pneumonia. But that’s just one chart. Further down there’s another that disagrees with it, saying that Pnemonia is the most significant disease and “Other Respiratory Disease” is nowhere to be found. Being unlabeled, I can’t quite tell what each of the charts is measuring and why they’re different. Bottom line is that Pneumonia is a big problem.
[9] http://www.health.go.ke/Healthfacilities/Annual%20Report%20_%20HMIS.pdf p143. This seems way too high. I would guess two things are working together: nutritional vulnerability (immunosuppression) and misreporting. I doubt many clinics actually culture their patients. It’s probably easier to give an antibiotic than X-ray or culture sputum. So any productive cough becomes “pneumonia.” Not that I’d recommend any changes to the protocol; a good H&P should have decent enough specificity and sensitivity.
[10] Assuming $1/day x 2 adults = 2/day*30 days/month = $60/month/family. Assuming 4 children/woman, the average family has 6 members and $60. If the health plan cost $1/person/month * 6 people = $6/month, then that would come out to 10% of a family’s income, which is roughly what the rich and middle-class pay in developed countries (the poor pay a much larger percentage in developed countries). Perhaps this is still too high to be feasible, but it puts it in the right ballpark. Maybe it could be even cheaper. The right thing to do is find out (as with any product) how much people are willing to pay, and then design a plan at that price point.
[11] Though the data they present does not support them, Anemia was complained of by the MOH; this is likely prevalent and under diagnosed. I read elsewhere that protein insufficiency is a problem, especially for children. It may be (though this theory is a total stab in the dark) that this is part of why everyone gets pneumonia.
[12] There is a lot of potential synergy with these seven and other areas of development. Improving water and sanitation would prevent a large amount of diarrheal disease; improving agriculture outputs (esp. protein, vitamin A; raising chickens and eating their eggs and livers would do wonders) would improve nutrition. Of course, business development improves all areas with more money to spend on needed things.
[13] Another consideration is that without the limited ‘insurance’ side, it’s not necessary to make this a monthly ‘plan’. In essence, a health plan without insurance is simply pre-paying for health services from the buyer perspective. The primary advantage to doing so for the buyers is to help them set aside money aside regularly for services we (the provider) think they should buy. The primary advantage to the provider is that health money can be pooled and invested in the community’s health; for example, no one person could make a health fair where doctors are within walking distance and services, by virtue of massive volumes, are inexpensive. But there is a small insurance component to it: not everyone is going to need emergency transport, not everyone is going to get pneumonia, not everyone is going to come to the health fair.
Also, with a limited plan, it limits moral hazard (doing dangerous stuff because you're covered) by only providing limited treatment to diseases which aren’t preventable, and prevention to diseases which are expensive to treat (HIV, Malaria). Because services are limited, it prevents providers from feeling the incentive to do more things. They’re not paid commission on the drugs they sell, and they only have a limited number of services. This would be taking Britain’s approach to limiting healthcare spending: limit the supply of medical services (you can’t get an expensive MRI if there aren’t any near you).
I just had a conversation with a biologist from the Democratic Republic of Congo (DRC). He is in the PhD program at UCLA. I was over at my friend Josh Beck's apartment and we had dinner with him. I asked him his perspective on Africa, its problems and his ideas on solutions and decided to email you what he said.
Background Neville has been working in Congo with the NIH (a US institution) on Monkeypox, an emerging disease with the potential to become as deadly as Smallpox. His advisor in Washington DC and he organized a massive sampling in the villages throughout DRC. In the end, he collected 15000 blood samples by trekking through the Congolese jungles. They are going to be processed in Oregon where they hope to track the mutation of existing diseases and identify new viruses that are emerging in the jungles.
He is one of the top scientists in DRC, which has one of the best educated populations in Africa. He was awarded a scholarship from the NIH to be trained as a PhD at UCLA.
Aid He is critical of aid as it exists today, but believes it is very important nonetheless.
The UN works with whomever the government tells them to work for, and then the clothes or food go to the families and friends of the government workers.
He also talked about how stupidly it is given. Right before he left, he told of visiting a neighboring country and seeing a very expensive piece of diagnostic/science equipment (a flow cytometer) just sitting collecting dust. France had donated it to help in the fight against AIDS, but there were no scientists who knew how to use it. Someone stole it thinking it was a TV, but after being unable to get it to work, he brought it back. The bottom line was if the machine were given to DRC on the other side of the river, it could have actually been used.
His idea is to connect with individual and trustworthy individual Africans who would be faithful in giving aid to those who actually need it. He said when he went out into the villages, that there were naked and hungry people. Most of the aid stays in the cities or goes to greedy politicians. He said he has many trustworthy friends that could be held accountable by being expected to show pictures and stories of children helped and with occasional visits to Africa. I've gotten his email and plan to follow up with that.
Technology There was definitely a Flat-World moment or two. When he was doing his research, he had a Land Rover that was connected with an antenna to a high-speed modem back in the city. He said he once was in a village 1000km away talking via Skype videophone to Washington DC to get advice on how to proceed in the Congolese rain forest.
He mentioned the cost of Internet was rather low, about a cent a minute. To call the US, it was 40 cents a minute.
Education He believes education is a major part of getting Africa back on its feet. He said he would help as much as he could, but he just didn't have the money to send everyone to school. A student really wanted to go to university, but couldn't afford it. He said the cost of attendance would be less than $1000 per year and that a degree took 3 to 4 years to complete. There are 2 year masters programs, but no PhD programs.
The thing he wants to achieve to build up the scientific world is collaborations between American and African institutions. Surprisingly to me, there are many Congolese scientists. They know all about what a Western Blot would be, but have no money to do them. There are no resources in DRC for researchers or students, so he proposes an exchange program. Americans could go to Africa to study Malaria as it really is, and Africans could come to America to learn how to use equipment and get trained.
Politics
I asked him what were some of the things that were different about America's culture that he noticed. The first thing he said was, "You are very hardworking."
The second thing he pointed out and admired was our patriotism. He thought our patriotism was important in our success as a country. He said, "Without patriotism, it is the death of that country." He believes that this is a major problem in African politics: the leaders aren't patriotic and don't want their country to be great. Their patriotism can be bought, so they sell their country.
He believes our biggest failing is in our ignorance of the world. "The world is a village," and we have no idea what is going on in it.
"That is what is lacking in Africa: men of principles". He respects America for its principles, or rather the principles of our founders that exist now only as a residual (He told a proverb of using a jar to store chilies, and then even if they are taken out, the jar will still smell of them forever).
Overall
It was a really cool night. I learned so much and got such an improved perspective on the world. I hope to actually collaborate with him and have an impact on Africa instead of just feeling bad.
