The Coming Plague (35 page)

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Authors: Laurie Garrett

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Though details of Soviet nonmilitary foreign aid policies were rarely disclosed, the bulk of its donated largesse went to Cuba, Vietnam, Laos, the Eastern bloc nations, and key strategic points of mixed Cold War allegiance, notably Egypt and India.
From both sides of the Iron Curtain, donors' monetary contributions to poor nations were all too often linked to prestigious showpieces: hydroelectric dams, international airports, university complexes, tertiary care hospitals. Usually ignored were community-based projects, such as schools, medical clinics, skills training programs, or public health campaigns. Worse yet, donors preferred one-shot investments, and disappeared for the long-haul maintenance of their high-profile efforts; even the dams, airports, and massive construction projects soon took on a shoddy, potentially dangerous reality under their previously polished veneers. Lacking the foreign exchange to purchase replacement parts, hire expertise, or carry out routine maintenance, the poor countries had no choice but to let cracks go unchecked in their dams, watch helplessly as the tarmacs of their runways deteriorated, and use staircases when the elevators of their fancy office buildings broke down. Over a third of typical developing country budgets was eaten up by recurrent costs, while donors insisted on funding only new, prestigious programs.
Nongovernmental investment in developing countries came exclusively from the capitalist and social democratic states of North America and Europe, and was heavily targeted toward the acquisition of vital resources. In Africa, in 1977, 56 percent of U.S. private investment was in petroleum, 26 percent in mining, and 6 percent in manufacturing.
12
From the socialist and nationalist movements and intellectual circles of South America and Africa emerged the dependency theory of development. Overall, the dependency theorists provided cogent criticisms of Western modernization strategies and investment policies, avoided issues related to Soviet activities, and had no consensus on an alternative approach to raising the standards of living and health of the people of the Third World. They represented more a force of opposition than an alternative scheme for development.
Most of these critics (notably such intellectuals as André Gunder Frank, Theotonio dos Santos, Fernando Henrique Cardoso, and Enzo Faletto) argued that acceptance of loans and aid from multinational corporations and lending agencies led to cycles of ever-greater dependency and debt. For
example, the poor country that wishes to build a hospital turns to a wealthy nation for donations and loans. Once granted, the hospital's construction leads to a new dependency on Western-style medicine, drugs, and machines. Purchasing replacement parts for American X-ray machines or French autoclaves exhausts the country's small foreign exchange resources. Eventually, the hospital becomes a drain rather than a boon to the society, adding a budget line to the Ministry of Health's already overdrawn accounts. The dependency theorists argued that poor nations lost out in two ways: they were compelled to purchase all equipment and expertise from the richer countries, and whatever products they, in turn, produced had to be sold back to those same wealthy-nation interests at prices set by the purchasers. This, they insisted, represented a lose-lose situation.
By the late 1970s even Western investors were beginning to recognize that modernization wouldn't inevitably bring twentieth-century European standards of living and health to the Third World. In the early 1970s the U.S. Agency for International Development had focused on gross national product (GNP) growth as the crucial measure of success for Third World countries. By 1977 the agency's administrator, John J. Gilligan, was compelled to reverse that policy.
“This approach had certain notable successes,” he said in a key policy address:
 
During the last quarter century, per capita GNP growth in developing countries has averaged three percent—nearly the same growth rate as the rich countries. Average life expectancy in developing countries has increased from 35 years to 50 years—the level attained in Western Europe only at the beginning of the twentieth century … . Some developing countries have achieved such high rates of growth that our grant aid to them has ended, and our principal form of economic interaction with them is now largely in trade and private investment.
These overall gains, however, have masked a crucial fact: that while some developing countries have achieved dramatic per capita GNP growth—some at rates of over 7 percent—many others have made very little progress. These averages also conceal wide differences in the extent to which various groups within the poor countries have benefitted from development. For in most less developed countries, the so-called modern sector of urban areas and large farms have been the major beneficiaries of growth, while the urban and rural poor—whose numbers have been rapidly increasing and who form the majority in most developing countries —have generally been left behind.
13
 
The World Bank didn't begin to view health care as a specific part of its mission until 1975, when its Health Sector successfully argued that trickle-down modernization would never adequately remedy the acute needs of the poorest of the poor. Between 1975 and 1978 the World Bank gave loans or provided technical assistance for seventy health-related projects in forty-four countries, ending up the world's biggest health lender. During
that three-year period, the World Bank loaned poor countries $400 million for primary health care facilities and mosquito control; $160 million for family planning and nutrition projects; and $3.9 billion for water sanitation efforts.
14
At the close of the decade, the World Bank again assessed its efforts, deciding to shift policy further toward provision of financing the development of primary health care infrastructures for, among other things, “promotion of proper nutrition, provision of maternal and child health care, including family planning, prevention and control of endemic and epidemic diseases.”
15
As the twentieth century drew to a close, the majority of the world's population still suffered and died from diseases due to unclean water.
16
During the 1970s one out of every four people on earth suffered diseases due to roundworms, acquired from polluted waters or foods. A World Bank study found that 85 percent of the residents of Java had hookworm. Some 1.7 billion people annually suffered some additional parasitic infection acquired from polluted water, according to WHO.
17
Sometimes a major water development project could directly increase the incidence of disease by changing the local ecology in ways that were advantageous to the microbes. The most often cited example of this was the Aswan High Dam, with its apparent association with an increased incidence of schistosomiasis.
18
Schistosomes are parasitic organisms with a complex life cycle in which, at different stages of the organism's development, the creature grows inside snails, on the surface of freshwater plants, and inside human beings. Its eggs are excreted via human waste into water supplies and are taken up by riverbank and lakeside snails. Inside the snails the eggs hatch and the organisms advance into the larval stage. Those larvae are excreted by the snails back into the lake or river, where they come to rest on the stems and leaves of underwater plants, usually along banks. People who bathe, play, or work in the watery area brush against these plants, and the larvae readily pass through their skin into the bloodstream.
Depending which species of schistosome is involved (
Schistosoma japonicum, S. haematobium, S. mekongi, S. mansoni, or S. intercalatum
), the larvae make their way into the human liver, spleen, urinary tract, kidney, rectum, or colon, where they grow into worms. The worms may remain indefinitely, secreting their eggs, which the human then passes on into water supplies, repeating the cycle.
The worms can produce an enormous range of illnesses in people, from minor local skin infections and virtually unnoticeable mild fatigue to life-threatening heart disease, epilepsy, kidney failure, and malignant cancer in the organs in which they reside. Because the range of symptoms is so vast, it is virtually impossible to say with certainty how many people in an endemic area have schistosomiasis: indeed, the definition of schistosomiasis has always been a matter of dispute.
Given the uncertainties inherent in schistosomiasis diagnosis, it was always difficult to prove specific trends in the incidence of the disease. Nevertheless, there was scientific agreement that the enormous Aswan High Dam radically changed the ecology of the Nile, slowing the flow of the once uncontrolled river, preventing annual floods, and creating the huge Lake Nasser. And those changes prompted shifts in the schistosome population.
For millennia nearly every Egyptian had lived in close proximity to the Nile, the rest of the country being largely desert, so the potential of human exposure to any changed disease risk along the river was very high. Yet at no stage of the 1950s planning or construction of the Aswan High Dam was the ecology of human disease taken into consideration, by Egyptian authorities, Western financial interests that initiated the project, or the Soviet government, which, with much fanfare, completed the dam.
The slowing of the Nile flow rates caused a marked shift in the types of schistosome species prevalent in Egypt, from
S. haematobium to S. mansoni.
For the Egyptian people this meant a shift from organisms that primarily attacked young children, mostly producing urinary tract disorders, to organisms that targeted young adults, causing often severe disorders of the spleen, liver, circulatory system, colon, and central nervous system.
19
Similar shifts in schistosome populations and human disease followed construction of the Sennar Dam in Sudan and the Akosombo Dam in Ghana.
The Aswan High Dam's impact on schistosomiasis was questioned by some because there was a lack of sound comparative data on the incidence of the disease in Egypt prior to construction. But there was an additional reason to challenge the wisdom of building massive water projects without first assessing their potential health impact: Rift Valley fever.
Carried by mosquitoes (
Aedes pseudoscutellaris
), the Rift Valley fever virus was, prior to 1977, considered largely a veterinary disease that primarily attacked bovine and ovine livestock, though sporadic cases among ranchers were seen. First noticed in 1930, when an outbreak of spontaneous abortions, stillbirths, and adult die-off occurred among sheep and cattle in Kenya,
20
Rift Valley fever epidemics occurred throughout Africa wherever European livestock species, which had no immunity to the virus, were introduced to the continent.
21
The virus produced hemorrhagic disease similar to yellow fever, with marked lethal effects on developing fetuses and newborns. In nonimmune animals its impact could be devastating: intravenous injections of minute quantities of the virus into laboratory mice produced death within less than six hours in 100 percent of the test animals.
22
In 1977, six years after completion of the Aswan Dam, James Meegan and his colleagues with the U.S. Navy Medical Research Unit based in Egypt proved that a widespread human epidemic in the Aswan area was due to Rift Valley fever. Over 200,000 people fell ill, 598 died of hemorrhagic disease, and livestock losses were so great that the country experienced severe meat shortages.
23
The scientists concluded that the
epidemic began as an isolated outbreak among livestock in northern Sudan, but spread—either via human migration or wind-carried mosquitoes—to Aswan. Once in Aswan, the infected mosquitoes thrived in the 800,000 hectares of dam-created floodlands. The disease had never previously been seen in Egypt.
Similar dam-related epidemics of Rift Valley fever would occur during the 1980s in Mauritania, Senegal, and Madagascar, and in the 1990s the disease would revisit Aswan, causing a severe epidemic.
24
By the mid-1980s major donor groups, particularly the World Bank, would acknowledge the health care downside to dam construction and instruct applicants for major water project funding to submit disease impact studies as part of their project proposal. In all cases, however, it would be decided that the benefits to society of hydroelectricity and flood control far outweighed the disease potential, particularly if steps were taken to improve local primary health infrastructures.
By 1980 the World Bank would conclude, belatedly, that the worldwide malaria eradication campaign had failed, noting that cases of the disease had increased an astonishing 230 percent on the Indian subcontinent over a mere four years' time (1972–76). Most other vector-borne diseases, just a decade earlier considered easy to eliminate, had experienced “a startling increase in their incidence over the last decade.”
25
Sleeping sickness (trypanosomiasis), bilharzia (schistosomiasis), river blindness (onchocerciasis), and Chagas' disease were all increasing in frequency, often in the very countries that had been recipients over the period of billions of donated and loaned U.S. dollars.
Something was clearly amiss. The world's leading agencies were forced to retreat from the grand optimism of the fifties and sixties. Explanations had to be found, blame fixed, solutions suggested.

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