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The end of poverty: economic possibilities for our time

2008; Wiley; Volume: 12; Issue: s1 Linguagem: Inglês

10.1111/j.1600-0579.2007.00476.x

1600-0579

Jeffrey Sachs,

Sustainable Development and Environmental Policy

Jeffrey D. Sachs is the Director of The Earth Institute, Quetelet Professor of Sustainable Development, and Professor of Health Policy and Management at Columbia University. He is also Special Advisor to UN Secretary-General Ban Ki-moon. From 2002 to 2006, he was Director of the UN Millennium Project and Special Advisor to UN Secretary-General Kofi Annan on the Millennium Development Goals, the internationally agreed goals to reduce extreme poverty, disease and hunger by the year 2015. Sachs is also President and Co-Founder of Millennium Promise Alliance, a non-profit organization aimed at ending extreme global poverty. He is widely considered to be the leading international economic advisor of his generation. For more than 20 years Professor Sachs has been in the forefront of the challenges of economic development, poverty alleviation and enlightened globalization, promoting policies to help all parts of the world to benefit from expanding economic opportunities and wellbeing. He is also one of the leading voices for combining economic development with environmental sustainability, and as Director of the Earth Institute leads large-scale efforts to promote the mitigation of human-induced climate change. In 2004 and 2005, he was named among the 100 most influential leaders in the world by Time magazine. He was awarded the Padma Bhushan, a high civilian honour bestowed by the Indian Government, in 2007. Sachs lectures constantly around the world and was the 2007 BBC Reith Lecturer. He is author of hundreds of scholarly articles and many books, including New York Times bestseller The End of Poverty (Penguin, 2005). Sachs is a member of the Institute of Medicine and is a Research Associate of the National Bureau of Economic Research. Prior to joining Columbia, he spent over 20 years at Harvard University, most recently as Director of the Center for International Development. A native of Detroit, Michigan, Sachs received his BA, MA and PhD degrees at Harvard University. He has been conferred with honorary doctorates from universities around the world for his extraordinary contributions in global economics, including one conferred by his close colleague Chancellor Mary Robinson from the University of Dublin, Trinity College. Jeffery Sach’s presentation on his book An End to Poverty to his colleagues in Columbia University was relayed as a keynote video presentation to set the context for the Global Congress and the 14 working groups. Only some of the moving images he presented are included in his keynote address. See: http://www.columbia.edu/cu/news/media/05/349_the_end_of_poverty/. Poverty will not be ended by sheer will power alone. It will not even be ended by ethical commitment alone, though ethical commitment is essential. It will be ended by bringing the best of our thinking and the best of our science, together with ethical commitment to attend to the very great problems of the world. It will require the thinking of scholars and scientists and committed practitioners from across the range of human knowledge. The Earth Institute is a unique place in the world; it brings together scientists, engineers, public health specialists and even a few economists to think, with the knowledge that they have the support and confidence of this university community. So I want to say how grateful and pleased I am to have this forum to introduce these ideas. I think we can do something marvellous in our generation. I think we can do something that no other generation in history could even contemplate. Not only do I think that we can do this marvellous thing, I think we must do it. This wonderful thing that I think we can do is to bring an end to extreme poverty on the planet and it can be accomplished by the year 2025. I would like to explain this first by introducing you to some of the people that I have been privileged to meet. I will show you some of the haunting images that I have experienced in many years of work in very poor places. This is the face of extreme poverty. We have to understand it. Before I saw these people and their circumstances, I could not have imagined it. Still, after 20 years working with these villages in all parts of the world, I continue to experience dreadful conditions I could not have imagined before. Nevertheless, horrific as the problems are, solutions are also at hand. The solutions can be found by a proper diagnosis of the causes of such poverty and suffering, and a proper understanding of the forces at play that have led to the fact that five-sixths of the world has escaped from extreme poverty. All of the world was once in extreme poverty. Not so long ago, perhaps less than 200 years ago, there were only a few dukes, duchesses, kings and queens that were beyond extreme poverty. The rest of our forebears were fighting for survival every day. We have had a scientific and industrial revolution. We have had two centuries of economic development (albeit at times violent and frighteningly unfair, and sometimes grotesquely exploitative), which were successful in raising living standards, in raising life expectancy, and in cutting sharply mortality and illness from infectious disease. But although that progress has reached a substantial number of people, it has not reached all on the planet. The success of global economic development in most of the world makes it possible for us to think of the one billion people who have not been part of that success. One-sixth of humanity continues to struggle daily for survival. Their extreme poverty is so forceful that it literally kills. It continues to kill by the millions each year because extreme poverty deprives people of access to the most basic tools for staying alive: safe drinking water, basic sanitation, a bed net to fight against malaria, a doctor in the case of a dreaded illness that is otherwise treatable, seeds, so that crops can be grown and hunger alleviated. This deprivation is extreme poverty and a billion people on the planet are still struggling with it. Meet some of them. In our travels we saw what our fellow human beings had to endure. There were regions where crops failed due to long dry seasons and erratic rainy seasons, and this was a year when the rains failed. One poignant example was a grandmother and her extended family of grandchildren but not her own children. They had had died of AIDS and left her many grandchildren without parents. In that village we saw very few mothers and fathers of working age; a community of grandmothers and orphaned grandchildren with a missing generation. They are hungry and they are fighting every day, at risk of malaria, a killer disease. Malaria will claim between 1 and 3 million lives this year, even though it is 100% treatable if you get the medicine in time. Moreover, it is largely preventable, if you sleep under a bed net treated with insecticide. These children do not sleep under such a bed net; as they cannot afford it. A bed net costs $5, it lasts 5 years, two children sleep under it. It therefore costs a mere 50 cents per child per year, and still the poorest cannot afford it. They have no money whatsoever. They grow crops but not enough even to feed themselves. This is in essence a non-cash economy for hundreds of millions of people. Carol Bellamy, the Head of UNICEF, called the situation in Malawi, ‘the Perfect Storm’: AIDS, endemic malaria, drought – a triple catastrophe. We saw this child (Fig. 1) in a subdistrict hospital in Western Kenya just 3 weeks ago. There is a tongue depressor in the mouth so that the child would not bite his tongue off. The child, most likely, had been given medication that does not work any longer due to the development of widespread drug resistance. These former first-line drugs are now often useless. You have children brought in a state of coma as this young boy was. We do not know whether he survived. We do not know whether he will live with lifetime impairment if he did survive. Child suffering from cerebral malarial, in seizure, admitted to hospital. When we turned the corner in this subdistrict hospital, we saw the paediatric unit – six people sleeping to a bed: three children and their three mothers. This is considered normal in Western Kenya. The burden of illness is so great that the hospitals are overflowing. Malaria, killer diarrhoeal disease, acute respiratory infection, paediatric AIDS are all rampant there. There is one nurse for every 70 patients. Think about that. It is about 5 min per patient for a nurse during a day shift. And these are not patients with mild problems. This is a system completely overwhelmed. Figure 2 shows an adult ward on a not so busy day. There were, after all, only two patients to a bed. How would you like to go into the hospital with malaria and be put on a bed shared with someone with tuberculosis? Not a very good idea. In a proper hospital, the TB Ward would be separated physically. You would not be sharing a room, or hallway, much less a bed! You would be in a different part of the hospital protected by ultra-violet lights. There would be another thing that you would expect: that the doctor would wash his hands between patients. You might expect running water in the hospital. In this hospital there is no running water. They cannot afford it. Only now, are they beginning to put it in. Two patients to a bed in a crowded hospital; one of them is suffering from malaria; the second is infected with active tuberculosis. The image in Fig. 3 is, of course, one of the picturesque sights you see anywhere in Africa, with this woman carrying water on her head - except when you stop to ponder the extreme poverty. Talk to the woman. You will find out that she might spend 6 h a day simply collecting water – not safe water, mind you, but water. An hour there, an hour back, three times a day. That is extreme poverty; a rite of continuing physical burden just to stay alive. Then we hear of their work ethic and such comments as, ‘they do not work hard enough’, when in fact they work to fight for their very survival and also the survival of their children day in and day out. A woman bears a water vessel for her family which may require her to walk for several hours; repeated two or three times every day of her life. Unfortunately this water is often contaminated. That is a good picture of a bad situation. That is a woman in a hut with particles in her lungs from a typical three stone cooking stove. This is what the air is like inside the hut at cooking time. This is why millions of children get acute respiratory infection and a vast number die each year, because the air inside is too noxious for the lungs; even in their own homes they are at serious risk every day from contaminants. Figure 4 belongs to the category –‘I cannot believe what I just saw!’ Even after 20 years of thinking that you have seen everything something even more appalling turns up. This was just 2 weeks ago. This is a picture of a group of men in a village in Tigray Province, Ethiopia, digging in the middle of a dry river to find the water which is about 5 feet under the surface of the river bed. This is what the village calls, their ‘perennial river’, in other words the year-round flowing river. The only problem is that it has stopped being a river. The water table is now beneath the river bed, partly because the rains have failed consistently in recent years. The short-season rains have now failed 5 years in a row. There are 11 000 people at this bend of the river where we were. They are fighting for their very survival. Their children are chronically undernourished, and it is a struggle to stay alive, to the point of digging for water in the dry river bed. This is extreme poverty – almost unimaginable until one sees it, and so horrific that one may be led to the false conclusion, as many are, that this suffering is now inevitable: a Malthusian catastrophe as human population has simply outstripped the carrying capacity of the land. Villagers dig to find water which is fundamental to the survival of their community. What can one possibly do? The fact of the matter is that everything that we have seen has practical, do-able, known proven solutions. We just do not apply those solutions, at least not anywhere close to the scale that is needed. The point of my book, The End to Poverty, is to explain that as horrific and shocking as it is that nearly 10 million people will die this year of diseases and health conditions and the chronic under-nutrition of extreme poverty, these problems have practical solutions. I believe the Earth Institute and the UN Millennium Project have played a vital role in creating awareness and showing a way forward. What do we know? Let us start with what we think we know, as it happens to be wrong. We think we know that there is a one-word explanation for this problem. If you ask virtually anyone in Washington what is going on in these horrific scenes, they will tell you it is easy, it is corruption. This is the very convenient and typical way in which rich people talk about poor people. Such comments emanate from people who have not, even once in their lives, visited an African village. They sit in all those buildings in Washington making stereotypical judgments and decisions. Something else is very important, and more to the point. The poorest of the poor live in the most marginalized physical environments on the planet. There are objective reasons that help to account for why they have not escaped from poverty while others have. There are three underlying risk factors. Why is Africa hungry and Asia not? First, Africa, unlike Asia, did not have a Green Revolution. There are many reasons. One of the reasons is that Asia has its great rivers, including the Ganges, the Indus, the Brahmaputra, the Mekong and the Yangtze, which serve to irrigate tens of millions of farms. Unfortunately Africa depends instead on rain-fed agriculture, without the vast river systems to provide irrigation. An astonishing 96% of the Africa’s cropland is rain fed. This results in extremely fragile farm systems which make it financially hazardous for the poorest farmers to purchase fertilizers and high-yield seeds. Their extreme poverty also prevents them from getting credits to buy inputs even when they would like to do so. The results are catastrophic. Without fertilizers, high-yield seeds and irrigation, the result is low and unreliable crop yields, and the depletion of soil nutrients which are not replaced by chemical fertilizers. So now, hundreds of millions of peoples in tens of millions of farm households are dependent on farming on soils that are biophysically deficient and cannot produce enough food to keep those families alive, much less to earn a market income. However, knowing these facts also helps us to find a solution. Fertilizer and small-scale irrigation techniques (many of which rely on harvesting rainwater, and then using the rainwater for supplemental irrigation) can change the face of Africa, as improved farm inputs have changed the face of Asia. A Green Revolution is now possible in Africa as it was in Asia. However, as happened in Asia, such a revolution has to be fostered; it will not just happen by itself. The study underpinning the UN Millennium Project has shown that Africa not only has a harder time growing food, it also faces a disease burden vastly greater than other parts of the world, malaria being the most notable. There are many ecological reasons for this, such as the kind of mosquitoes that thrive in such a climate, as well as the high temperatures which result in a higher intensity of disease transmission. Moreover there are also severe transportation problems. The distances of populations from ports and navigable rivers are far greater in Africa than in most other parts of the world. What, then, are the lessons to be derived from the challenges of food production, disease control and transport? The key point is that there are identifiable explanations for why the poorest of the poor are caught in a trap of extreme poverty, infectious diseases, hunger, low food yields and economic isolation. Each one of them has a ready list of practicable solutions which can overcome the challenge. Malaria can be controlled, indeed completely treated. Yet it has trapped the poorest of the poor because they are too poor, in fact, to finance the steps needed to control the disease. People far from the coasts are poor because they cannot trade; and because they are poor they cannot finance road construction to facilitate the access necessary for international trade. Farmers are impoverished because their soils are depleted of nutrients and the rains are unstable and unpredictable, yet the farmers lack the creditworthiness to invest in better seeds, fertilizers, irrigation pumps and the like. I propose there is a way out of the poverty trap. I learned the approach from my wife, an excellent clinician who was wise enough not to go into economics! She went into paediatrics and I have watched for >20 years how she skilfully performs a differential diagnosis. When a patient calls with a fever she does not say, ‘well you were corrupt.’ Nor does she say, ‘you have an earache.’ A good doctor knows there are 50 or more reasons for fever and that the key step is to figure out which of these possibilities applies to a particular patient at a particular time. My wife takes the time to listen to the patient’s symptoms, to observe the clinical symptoms, and to carry out a differential diagnosis to find the underlying causes of the patient’s fever. The first question is ‘Is your neck stiff?’, because if it is the underlying condition might be meningitis, and the patient must get to the emergency room before the second question. If the doctor can rule out meningitis, then the task is to keep ruling out other possibilities until an accurate diagnosis can be made. We have to do better in economics. We have to do better in the practice of economic development. We have to put development on a scientific basis. We economic development specialists also need to learn to be good clinicians. We do not need a 1-page textbook telling us that all is due to corruption. We need 32 chapters: one for mountain economies, one for rain-fed agriculture, one for depleted soil nutrients and one for malaria ecology. When you look at the last 10 000 International Monetary Fund documents the word ‘malaria’ was hardly, if ever, mentioned. Quite simply, the development institutions are not yet doing serious analyses. So how can we do serious clinical economics? You must start, like a doctor, by taking a ‘history’ of the village. You learn a lot by talking to very smart yet impoverished people, who are completely aware of their dire situation and who will join you in problem-solving in order to identify effective ways out of their poverty. In Ethiopia, thousands of people came to greet us last month, to talk with us about the real challenges of extreme poverty in one of the most desperately poor, but also one of the most dignified and wonderfully welcoming, places on the planet. We met the committees and the councillors who make decisions. When you do that, you can identify together lots of practical solutions. This is a picture of our wonderful star mechanical engineer, Vijay Modi, who has solved one problem after another regarding water pumps, cook stoves, household illumination and many other practical things that need to be performed. Follow Vijay, and you will discover many simple solutions, for rainwater harvesting, safe and efficient cook stoves, low-cost illumination, new energy sources and much more. Such simple and inexpensive tools as a treadle pump have made enormous contributions in Ethiopia when the water table is high enough. But they cannot afford it on their own. We have been moved by the many examples of benefits of replenishing the soils with nutrients, both chemical and organic; in some cases using nitrogen-fixing tree crops. We have been shown bumper harvests that can be achieved when the soil nutrients are replenished. Simple and uncomplicated water control and retention techniques can be very effective. Such innovations, for example using rocks to dam rain water, can save precious soil from erosion when the water rushes down from the mountains. Simple interventions can make a huge difference. The community asked us for some mesh to keep the rocks in place so that the stones do not get washed away by the mountain streams. The mesh they needed is not that expensive but they were unable to afford it because of its relative expense. School attendance can skyrocket through interventions as simple as school meals. In one community in Western Kenya, the school was ranked near the bottom in the district in the eighth-grade national examination. School meals were introduced and the school performance soared. The school is now ranked fourth in the district and the headmistress says ‘if you feed children, they can pay attention, they can learn and they come to school.’ With locally produced food, we will able to help this community expand the number of children in the school-feeding programme. This is something that should be performed in thousands of villages around the world. Mid-day school meals pay wonderful dividends in terms of healthier children, better learning, and higher school attendance and completion rates. One very simple and inexpensive malarial preventive strategy is to use nets to protect against mosquitoes, the vectors of the disease. Nets which cost $5 are pre-treated with insecticide that will last for four or five years without the need for retreatment. The number of deaths from malaria could be reduced by a million within the next 2 or 3 years by a mass distribution of insecticide-treated bed nets and by access to effective medications. The arrival of anti-retroviral medicines in many subdistrict hospitals has been very exciting. As a result, HIV/AIDS patients will not be dying abandoned in their huts, but will get medicine and be up soon and back to their families. It costs about 30 cents a day now to treat AIDS with an anti-retroviral fixed dose combination, and every infected individual ought to be getting this. We started 21 years too late. It is been a heck of a fight. It is inexcusable that we are not scaling up the fight against AIDS even more rapidly than we are. Figure 5 shows a building under construction and is a marvellous demonstration of what a community can achieve. We said to the villagers in Sauri, Kenya, that we would provide a doctor and medicines. They said they also wanted a new clinic, and in 5 weeks the community put up the new clinic! The Millennium Village Project provided the cement and the wiring and the community built the rest. Now the village has a clinic and a doctor and an ability to treat the children and the parents in this village. This is a picture of the community health workers, who, when we asked them ‘How can we help you?’, responded: ‘We want you to train us better, so that we can be proper community health workers.’ And they are now studying, working hard and upgrading their skills. They want to stay alive and they want to keep the village children alive. Construction of a new hospital exemplifying what can be achieved. What are the lessons? The main lesson is we must understand that we are dealing with other human beings; we must understand that we are dealing with people fighting for their lives; we must understand that we are dealing with people whose first objective is not to take our money but to keep their children and themselves alive. We must understand that we are dealing with people who know and understand their situation and who have creative ideas, knowledge, experience, skills and commitment. We are dealing with people who in the midst of an AIDS pandemic and chronic hunger, can put all of their recent eighth-grade class through success in the eighth-grade national examination. Yes, these people are fighting for their children and their children’s futures. They do not need much. My book shows financial estimates of what would be needed to address the basic needs of the poorest of the poor, and to do so in a way that helps them to get on the ladder of economic development. We can help create a situation where these communities can grow enough food to feed themselves and bring a crop surplus to market. Indeed, we can help these communities to shift some farmland to high-value cash crops. We can also help to introduce other kinds of activities, such as furniture making, food processing, metal working, selling milk and honey, and many other activities that would put these communities on to the first rung of the development ladder. The cost of these solutions turns out to be so shockingly small that it is almost unimaginable. For 35 years, the rich world has promised that it would give 0.7% of our incomes to help the poorest of the poor. That means we have promised that we would give 70 cents out of every $100 for development assistance. Imagine only 70 cents out of $100. Most Americans think we do 20 times more. They do not know that we only give 17 cents out of every $100! This year, the USA will spend $650 billion on the military and only $5 billion for all of Africa. The rich world is so badly failing to honour its own aid commitments and it is so dangerously directing its overseas efforts to military means rather than peaceful development, that the world is becoming more dangerous, more unstable and more divided. The USA pledged to make efforts to reach 70 cents out of $100 in official aid. The US Government denies that we ever made any commitment, but we did, in the Monterrey Consensus agreed in 2002, at a meeting in Mexico personally attended by President Bush. Specifically, Paragraph 42 of the Monterey Consensus says, ‘We urge developed countries [and that means us] that have not performed so, to make concrete efforts towards the target of 0.7% of the Gross National Product in official development assistance.’ If we, the Europeans, the Japanese and other rich countries would simply follow through on our commitment we could resolve the consequences of global poverty. Our generation can give the greatest gift to our children and to our new century, i.e. that we can realistically foresee the end of poverty in our time.