Why the developing world needs infrastructure as much as aid

Miracles have happened in global health over the last fifteen years. Deaths from malaria and tuberculosis have each fallen by a quarter or more globally. Twelve million people in sub-Saharan Africa with HIV/AIDS were put on lifesaving treatment.

The great killers of children – pneumonia, diarrhoeal diseases, measles, whooping cough, and diphtheria—are receding. The once fearsome scourges of polio and Guinea worm are on the verge of extinction.  

While the war against microbes is hardly over, the need for continued vigilance should not blind us to the great progress that has occurred. For the first time in recorded history, plagues, parasites, and other infectious diseases are no longer the leading causes of years of life lost to death and disability in any region of the world.

In 1950, one out of five children perished before their fifth birthday in nearly one hundred countries, including almost every nation in sub-Saharan Africa, South Asia, and Southeast Asia. Today, the number of countries where one out of five children die under the age of five is zero. The average baby born in a developing country is now expected to live to 70. 

But the sustainability of this era of miracles in global health is uncertain. The recent gains in longevity and child survival in many countries have not been accompanied by the same economic growth, job opportunities, and infrastructure improvements that occurred with those changes in today’s wealthy nations. 

When higher-income countries took on the scourge of infectious diseases, advanced medicines played less of a role than today. Nearly two-thirds of the gains in U.S. life expectancy that have happened since 1880 predated widespread access to antibiotics and most vaccines.

Only half of the declines in death rates in developing nations between World War II and 1970 were due to vaccines and antibiotics. Instead, the drivers of public health progress were government measures like quarantines and housing reform, investments in effective water and sewage systems, and improvements in girls’ education and child care. 

This combination of better health and broader social improvements was a recipe for prosperity in many nations. The economist Robert Gordon has cited “the historic decline in infant mortality centered in the six-decade period of 1890–1950” as one of “the most important single facts in the history of American economic growth.”

China was poorer than Chad, Benin, or Niger when it began a dramatic campaign against plagues and parasites after World War II that helped it later emerge as one of the great global economic powers. 

In contrast, medical innovations and global health aid initiatives are driving more of the recent progress against infectious diseases. Beginning in 2002, global health aid to reduce child deaths, maternal mortality, and the infectious diseases in poor countries rose more than 10 percent annually over a decade, expanding from £8.25 billion to £21.6 billion.

From shantytown slums in sub-Saharan Africa to the rural highlands of Peru, aid-funded programs brought medicines, vaccines, and insecticide bed-nets to world’s poorest people.  

The returns on those investments are spectacular and measured in longer lives and the reduced suffering of children, but broader economic and social benefits of improved health have remained elusive. While extreme poverty has declined everywhere, the middle class, individuals living on $10 to $20 per day, has hardly expanded at all in South Asia and Africa, the places that have recently seen the greatest health improvements.

When low-income nations finally achieved an average life expectancy of 60 in 2011, their median GDP per capita (£815) was a quarter of the wealth that the residents of high-income countries possessed when they reached that same average life expectancy in 1947 (£3371).  

In too many countries, too little is being done to ensure that the children and infants surviving to adulthood find adequate health systems and employment opportunities to accommodate their needs as adults. The governments of all 48 countries of sub-Saharan Africa spend less on health care than the government of Australia.

With limited access to health care and many people still too poor to purchase it out of pocket, cases of cancers, diabetes, and heart diseases are surging in many lower-income countries. Foreign aid to address these noncommunicable diseases has been lacking. The disparity in adult health –life expectancy at age 15 – between wealthy and poor nations is growing, even when one ignores the effects of HIV/AIDS.  

More people surviving childhood and adolescence used to mean more workers for factories and mills. But manufacturing only employs 7 percent of the workforce in sub-Saharan Africa, and manufacturing represents the same share of overall economic output in that region as it has since the 1960s.

The World Bank estimates that the working-age population (more than 15 years old) in developing countries will increase by 2.1 billion by 2050. Unless current national employment rates improve, that will mean nearly 900 million more young adults without work.

The recent declines in infectious diseases present an historic but time-limited opportunity. With steeply rising rates of child survival, more sub-Saharan Africans will reach the ages of prime employment (ages 15 to 64) by 2035 than will be added by the rest of the world combined.

While sub-Saharan Africa has greatly increased school attendance, up to 40 percent of children in the region still do not meet basic learning outcomes in numeracy, and half fall short in literacy. Without more investment in quality education, capable health care systems, and workforce development, large numbers of underemployed and under-productive young adults can be a recipe for instability and higher rates of migration.  

Prime Minister Theresa May wants to shift the focus of UK development assistance from childhood vaccines and nutrition to boosting jobs and private investment and tackling problems such as corruption and illegal migration.

Adjusting development assistance strategies to address emerging challenges is welcome, but giving people cash or encouraging private investment alone will not provide the roads, quality primary health care, or the urban sanitation and enforceable land rights that many low- and middle-income countries need.

We live in an era of great and welcome progress in the global fight against infectious disease. That fight must continue, and we should continue to invest in it. But we must also recognise that progress against plagues and parasites cannot be measured just against the countless lives that were once lost, one by one, to those infectious diseases.

The real miracles in global health happen when lives are saved in an environment where those individuals can seize precious opportunities and prosperity that have come with health improvements in the past.

• Thomas J. Bollyky (@TomBollyky) is the Director of the Global Health Program at the Council on Foreign Relations. His book Plagues and the Paradox of Progress: Why the World Is Getting Healthier in Worrisome Ways was published by MIT Press on September 27, 2018.

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