I'm in awe of all of you and want to congratulate all of you -- the graduates and award winners -- and tell you how thrilled I am to be among you, to sneak in for an award in biomedical research. It's a profound honor.
If I think about it in biomedical terms, my work involves trying to change one base pair -- one single-site polymorphism, I suppose. I'm trying to change "M's" to "B's" -- millions to billions in the amount that we spend to fight disease and poverty -- and to show how, if we do so, we have a chance to make a safer world. I'm also trying to help you achieve the wonderful things you're achieving in stability, with the proper financing, so that the wonders of science can unfold under your remarkably skilled eyes, hands, and brains.
Certainly, as an economist, I'm here by accident. I worked on exchange rates for a long time. I worked on budget deficits and international finance, and I worked in some of the poorest countries of the world. But for a long time, I viewed those countries through the optic that is useful for viewing budgets and trade.
But starting in the mid-1990s, I found myself in Africa for the first time. That was the beginning of what has been, over the last 12 years, an astounding adventure of learning, and of intellectual growth, and of profound human opportunity.
When I started work in Africa, even after having worked in India, China, Eastern Europe, the former Soviet Union, the Andean region, and many other parts of the world, the overwhelming fact was death -- death everywhere, death that I had never conceived possible. There was the death of seven of our counterparts in the Ministry of Finance in the central bank in Zambia in a short period of time, at the onset of a macroeconomics project. People would go home on a Friday and never come back, because AIDS was striking down a generation of the best and the brightest, the mothers and fathers of the country. Through all the headlines and grim realities of the disease I had never allowed that kind of devastation to penetrate until I started to experience it face to face.
And then I saw malaria everywhere. This was also something new for me because even in the tropics in other parts of the world, malaria had been substantially controlled, if not fully eliminated. Yet malaria was pervasive, holoendemic, I learned, throughout most of the continent. It struck the rich and the poor. It killed children. It threatened the lives of Africans returning from study abroad after their long built-up immunity had vanished after just one or two years overseas.
With all that poverty, I naturally asked myself some questions as an economist. First, what are we doing about this? I was so stunned by the grim reality that I could not understand.
Second, I asked myself on an intellectual level -- what does this massive disease burden have to do with the massive poverty around? Is it simply a reflection of the poverty? Or could it be one of the reasons, in fact -- one of the causal factors in Africa's relative and absolute lack of escape from extreme poverty -- an escape that almost all the rest of the world had already achieved?
So I went to the economics literature and found one paper in the last 50 years on malaria, which shows you how disconnected academic work -- in my field at least -- can be from grim realities. I salute the author of that paper from the mid-1960s, but I don't think he got it right. His conclusion was that malaria probably raised the per capita income by lowering the population, thereby mechanically raising the relative income.
That is not the right conclusion when you think a little more deeply about it. What had been observed ever since Ross discovered the basic pathways of malaria 100 years earlier was the fact that malaria and extreme poverty went hand in hand geographically. [Sir Ronald Ross was awarded the 1902 Nobel Prize in Physiology or Medicine for his work on malaria.] What had been observed is that when malaria began to be brought under control in different parts of the world -- whether it was rolling back malaria from the marshes of Rome, or the elimination of malaria and yellow fever from the American South in the 1930s and 40s, or the control of malaria through chloroquine and DDT in the 1950s in many subtropical regions -- a takeoff in economic growth was a proximate factor that appeared afterwards. There seemed to be something more than correlation, indeed, causation at work.
This was also the time when the AIDS pandemic was first being recognized, and so Africa was battling on multiple fronts. So I asked the second question, which I'm trained to do as an economist -- that is, to know the difference of "M's" and "B's" -- and to ask what were we doing about these two diseases. Especially after the discovery of the antiretroviral cocktails and the success of treatment that had come in the mid-1990s.
The fact of the matter was that there were almost no resources being expended by the rich world on behalf of the poor world. So here it seemed to be the case that disease was not only pandemic, it was not only tragic, but it was also essentially unattended to. If you think back to 1998 - 1999 -- and I couldn't believe it when I first published results in The Lancet in 2001 -- the total amount of reported spending on HIV/AIDS programs from the rich world for all sub-Saharan Africa per year, was $70 million. This is when there were already 25 million HIV-infected individuals. And yet there was not one single African on antiretroviral treatment as late as the year 2000 on an official donor program. Only very tiny projects of Médecins Sans Frontières and others had started the idea that Africans and other poor people in other parts of the world merited life-saving interventions.
I was very lucky -- twice lucky -- in 2000, to be asked by Dr. Gro Harlem Brundtland [Director-General of the World Health Organization from 1998 - 2003] to bring together the financial world, which I knew, with the public health world and the medical world, which I knew by marriage -- having been married to a clinician for 20 years -- but didn't know at a professional level, as Director of the Commission on Macroeconomics and Health.
And my double luckiness was of course to have [MSKCC President] Harold Varmus as one of the commissioners. Very briefly, we looked at three questions. First, is health a causal factor in economic development? And, "contrary-wise," is disease a causal factor in the failure of regions like Africa to escape from poverty? The answer is clearly yes.
The places with the disease ecologies most conducive to transmission of these vector-borne diseases, such as malaria, have had the hardest time and the latest start in economic development.
Just one causal footnote to this: in addition to the obvious factors of low productivity, taking life and health away from young populations who should be in their productive prime, and impeding foreign investment into malaria zones, is also the fact that the demographic transition from high fertility rates to low fertility rates -- essential to successful development, enabling poor families to invest more per child in their health and education -- is impossible when children die in large numbers. So the irony is that where child mortality is high, fertility rates remain even higher in compensation. Population growth rates are the fastest in the world, and economic development is impeded for demographic reasons alone.
The work of the Commission helped us to learn and understand two more things. The second thing was that the disease conditions that explained an overwhelming proportion of the difference in health between the well-off and the disease-impoverished countries could be reduced to a limited number of factors -- mostly infectious diseases, nutrient deficiencies, and unsafe childbirth. In fact, if you take AIDS, malaria, TB, diarrheal disease, acute lower respiratory infection, vaccine-preventable diseases, micro- and macronutrient deficiencies, helminthic [parasitic worm infestation] and other parasitic infections, and unsafe childbirth, you get about 80 percent of the excess disease burden in Africa compared with the United States.
Africans die of cancer in large numbers as well, but that does not explain most of the difference in the death rates. It's largely the lack of control of infectious diseases that explain the difference.
The third part of our work was to identify what could be done, whether about AIDS on both prevention and treatment; or malaria, with something as simple as an insecticide-treated bed net, or the latest-generation artemisinin and combination therapies; or Directly Observed Therapy, Short-Course Strategy for tuberculosis; oral rehydration for diarrheal disease; antibiotics for acute respiratory infection; a three-cent dose of mebendazole for helminthic infections; or emergency obstetric availability such as a C-section or other care for the half-million mothers who will die in childbirth in the impoverished countries this year.
For every one of these conditions there is a known, low-cost, proven scientific answer that could be available universally and has indeed been promised. But the fact of the matter is that for most of the poorest of the poor, these promises have meant nothing. And even today, approximately 11 million children die every year of readily preventable and treatable causes. The total cost as we determined it in a careful measure -- I think the most detailed that had ever been made -- is that these life-saving, life-extending, and preventative treatments could reach the poorest of the poor at a cost to us in the rich world on the order of one-tenth of one percent of the gross national product. That's $30 billion a year of a $30 trillion annual income in the rich world. It's a little shocking how hard it is to find that one-tenth of one percent in the rich world while more than ten million lives per year are at stake.
Nevertheless, the Commission did have some effect. I think it's fair to say that we were the progenitors of the Global Fund to Fight AIDS, TB, and Malaria (GFATM). AIDS treatment has gone from that $70 million to about $6 billion a year. We have gone from the "M word" to the "B word" -- at least in respect to that disease.
Malaria has suffered in relative terms because the activism and the outspoken community in this country, which has fought for expanded AIDS treatment so wonderfully, valiantly, boldly, and bravely, naturally does not have the same voice when it comes to malaria. The mosquitoes stay in Africa, the disease stays in Africa, and it's little known in this country that two to three million children will die this year mainly for want of an insecticide-treated bed net that costs five dollars, lasts five years, and sleeps two children. So something on the order of 50 cents per child per year is what we need right now to potentially save two to three million lives per year.
Now, it's actually almost as simple as that. If you look at the difference of economic success and economic failure at the bottom of the world -- why India took off, why China took off, and why Africa has not -- I think it's fair to say that the appropriate technology brought to bear to meet the basic needs of survival, as well as demographic change, adequate food production, and nutrition are the most important factors of all.
Wonderful discoveries in medicine and public health have also made a profound difference at every stage of economic development in all parts of the world; and agronomic science has been decisive as well. The Rockefeller Foundation helped to bring about the genetics of the Green Revolution, carried to India in the mid-1960s. And that enabled an explosion of food productivity that changed the face of nourishment and allowed a take-off of economics that linked adequate food supply, productive farming, and public health interventions. And that's why India today, while still poor, is on its way -- in a most historic way -- out of extreme poverty.
The same can be done in Africa and other parts of the world that have lagged behind. Almost inevitably, they lag because their circumstances are tougher. The disease epidemiology is tougher. The water management is tougher than in the monsoon environment. The river irrigation is lesser in Africa. The food yields are harder to achieve. But in every case, modern science has already delivered packages of effective technologies that, if brought to bear, would not only change lives and save lives by the millions but would enable children to have a future. And, as has happened in India and much of Asia, would enable these still-poorest parts of the world today to get on the same kind of economic path.
This, I think, is one of the greatest challenges that we face. It's no accident that Osama bin Laden said the jihad should go to Sudan. He will take the jihad to Africa. A general from the U.S. Army in charge of security [in the African command] said to me recently, "We can never do our job as long as the continent is hungry and disease-ridden because no army can help to create stability and safety in those circumstances."
At the core of hope, though, lies science. If it weren't for the science that identified the pathways of disease transmission for malaria, or identified the still-imperfect but powerful solutions for microbacteria, and that has allowed so much of tuberculosis to get under control -- if it weren't for the new genomic hopes, new pathways for vaccines and so on -- we would not be able to keep ahead of the curve.
The breakthroughs in economic development, from the beginning of modern economic development two centuries ago, have been science-based without question -- whether it's in energy or agronomy or in public health. We have powerful tools already, thanks to the breakthroughs that have been made, that we can help to bring to bear for the poorest people of the world, to save lives, and make our world safer.
We also have remarkable new opportunities for new science and even greater breakthroughs in the future. Those are the ones that are going to extend lives and are going to give us even more powerful tools that really are going to make the safe, secure, and peaceful world of the 21st century.
