by Siegfried Othmer | December 15th, 2004

The amount of true foreign aid (i.e., non-military development support) given by the United States is now down to about one tenth of one percent of our GNP (0.13% according to one account). At such levels there is a complete mismatch between resources and needs, so one might well use the idea of triage to answer the question about how such limited resources might be deployed. This was done at this year’s Copenhagen Consensus Conference by some esteemed economists. They deployed an imaginary budget of $50 Billion in the following way: $27 Billion for fighting AIDS; $13B for fighting malaria; and $12B for improving nutrition. Finally they proposed an initiative to reform international trade, which had no monetary impact. The astute will observe first of all that they over-committed their budget by 4%, but it would be frivolous to quibble, since nothing of magnitude is going to be available near term in any event. So it is far more important to contemplate that if $27B is the realistic cost of tackling AIDS with prospects of success, then what does the absence of such funds imply? The problem here is in our face more even than global warming, or the threat of international scourges by opportunistic diseases. This is here and now, with Asia, including India, China, and Russia at the threshold of a tipping point into runaway conditions. In Africa, of course, we are already at the point where AIDS is eating away at the core of societies that were at best functioning marginally before.

A couple of years ago, President Bush went to Africa to announce a five-year $15B plan to fight AIDS. Iraq got in the way. An economist would analyze this in terms of opportunity cost—in this case the opportunity to avoid future costs. The commitment to Iraq delayed a commitment to AIDS, under conditions where such delay has grave and near-term consequences.

But the economists can be challenged as well. What is “reforming trade” doing on this list? This had no immediate impact on the budget they drew up, for sure. But what could have put this in the triage category, even in the mind of an economist? Consider how improving international trade might impact on the other items on the list. (The list, after all, is not exhaustive, and if the list were longer, the other items would look very similar to the ones already on the list–water quality, for example, and basic public health measures, and the education of women.) The answer is hardly at all. No matter how well international trade flourishes, there is at best a trickle-down effect to the poorest economies, and it is a long way until they can utilize those resources to bootstrap their way out of their problems. Meanwhile, the distressing reality is that with expanding trade the dependency of most under-developed countries has in fact gotten worse.

It is evident to such observers as Bill Gates that problems like AIDS and other diseases must be targeted directly. To hope for improving economies to deal with these and other urgent problems is like hoping for democracy in Iraq. It would be foolish to expect quick results. Meanwhile the problem has a larger growth rate than the solution. Economists get that part, so how is it that they can put such a large store by such slow and gradual remedies? Is it possible that in this instance the economists are serving their masters? After all, their proposed remedy so perfectly matches the desires and interests of the economic elite in the developed world. Or have they become the masters, the secular priesthood of our age?

It is true that ultimately the growth in the domestic economy must support the solutions to local problems. But for any major problem in which the growth rate exceeds the rate at which remedies are being brought to bear we must have a targeted solution. We all know the implications of exponential curves, and when these relate to negatives they must draw our attention or we will just confront an even more intractable problem later. It is a trivial truth that any factor exhibiting a low growth rate cannot be a remedy for something exhibiting a higher growth rate. So by including economic growth in the triage category perhaps the economists are just offering up a little prayer that while we are killing alligators we also need to be thinking about draining the swamp.

They also know of the covariation of indices of health with those of economic status. In the case of blacks in the United States, for example, there is one predictor of mortality and morbidity that beats all of the usual suspects: smoking, obesity, high blood pressure, alcohol consumption, drug use, etc. It is socioeconomic status. But in this case we are looking at a subsection of our society, where the option of living a healthy existence is accessible. There are perhaps four principal factors that account for the correlation of health status with socioeconomic status: nutrition, mental health status, educational level, and the fact that access to good care in the United States comes with a price tag; i.e., the absence of universal health care. The growth in health care as a percentage of our economy, from 4.5% seventy years ago to about 18% currently, indicates that mankind will purchase health care as a high priority when it is available.

An attempt has recently been made to review our own Western European and American history in order to discern the factors that allowed our societies to escape mire, penury, suffering, disease, and early death over the last couple of centuries. Robert William Fogel, Nobel economist, has written the book “Escape from Hunger and Premature Death, 1700 — 2100: Europe, America, and the Third World.” I have only read the review of it in the New York Review of Books (October issue). He credits a “technophysio” revolution, a large part of which relates to the physio part rather than the techno part of the industrial/scientific/informational revolution. Our Western civilization has succeeded in producing 50% increase in body size and a doubling of longevity over the past 300 years. This Fogel ascribes largely the relief of chronic under-nourishment, a fact that surely has implications for the Third World.

In fact, Fogel sees population height and weight as an excellent predictor of health risk and mortality. More importantly for his argument, it is nutritional status that finally makes surplus energy available for work. Fogel attributes 50% of British economic growth from 1800 to 2000 to increases in dietary energy available for work, and increases in the human efficiency to transform that energy into work output—improved metabolism, health, and longevity.

Significantly for our considerations, Fogel finds that the body’s response to an inadequate food supply is a trade-off of current metabolic needs for an increased life-cycle risk of morbidity and mortality. This speaks volumes. A recent experiment with birds found it impossible to train birds to forego the smaller morsel in the moment for the sake of a larger morsel later. The birdbrain that can navigate to South America or find a particular swamp in Louisiana is incapable of foregoing an immediate response to a nutritional need in favor of a delayed reward. Perhaps this can explain a lot of things. For example, whereas the health status of blacks is poor, there is still less morbidity and mortality than is expected for the level of obesity that exists. It has been suggested that dietary indiscretions (you know, carbs) may in fact be contributing to improved mental health status in the moment, even though there may be long-term costs. The same may be true of tobacco and alcohol. So even at the human level of decision-making, there is a bias toward solving the immediate problem and meeting the immediate need. The long-term downside is a secondary consideration.

How do things sort out between the mother and its fetus? Does biology put emphasis on the survival of the mother or the fetus? Matters may not be clear, but the statistics are grim in their implications that malnutrition and trauma in utero or in early childhood eventuates in developmental deficits and significant health impacts later. Spontaneous abortions early in gestation are quite commonplace. Is our biology making an implicit calculation here of being willing to cut its losses when the “investment” in the fetus is not yet large? So early on the mother is totally favored, whereas later the fetus gets more consideration and respect. In the case of marsupials, where the mom has an immediate choice in the matter, she will chuck Joey in a moment of crisis. Long-term success is predicated on survival in the near term.

Where does this leave us with regard to our “triage” strategy for deploying the meager resources we commit to the Third World, and by extension to the underclass in our own country? The case for addressing HIV/AIDS is obvious. But similarly obvious is that malnutrition, water quality, and mental health status need to be targeted directly. We cannot wait for the invisible hand of the market. We cannot start the process of development with a commercial transaction any more than we negotiate with our fireplace: “Give me fire and I will give you wood.” (With thanks to Mark Steinberg, to whom I now owe a nickel.) A market mechanism cannot balance short-term and long-term rewards. Poor people will always choose food over seeing a doctor. We need to get ahead of the adverse exponential growth curves, and the sooner the better. Triumphalism among the market fundamentalists will not get us there.

In fairness, the economists of the Consensus Conference did list nutrition as a priority item. And Fogel, also an economist, sees the connection between nutritional status and mental health. Nevertheless, other perspectives are badly missing, for example those of a sociologist.

Fogel sees the trend toward larger health expenditures as positive. “The increasing share of global income spent on health care expenditures is not a calamity; it is a sign of the remarkable social and economic progress of our age.” As an economist, he sees this as the flipside of food, housing, and clothing costing less than before. And a lot of the growth comes from expenditures that are discretionary, in line with our changing value systems. He projects a further 30% increase in the fraction of national income committed to health over the next thirty-five years. And within this growing part of our economy, attending to problems of the central nervous system will win an increasing share. Further, within the increasing share that will be devoted to the CNS, there will be a growing share devoted to functional medicine, not to mention the whole domain of optimal functioning. That is where we come in. Neurofeedback could be the technology that exhibits one of the highest growth rates over the next several decades. It should be quite an adventure.

Given the theme of this piece, does neurofeedback have a place in the triage strategy for the Third World? Absolutely. In the management of trauma, and in the management of depression, which is on the way to becoming the largest health issue worldwide. But in this case also one should not wait for the invisible hand of the market. Market-pull will be too long in coming.

The increasing amounts we spend on our own health in this country put into even greater relief the pittances we mete out to help the rest of the world with its problems. There is a moral indictment here. Our own society used to do so much more when it had so much less. The indictment looms even larger when it is considered how tractable the amounts are that could manage these major challenges.

Even in this unfavorable environment neurofeedback may be in a relatively good position. Just as it has grown in this country essentially without sponsorship of the elites, and without the infusion of major capital, it can spread in the non-monetized economies readily because of a low cost of entry and low infrastructure costs. With technology priced at iPOD level, and able to serve many individuals with a single unit, price should not be a barrier. Can a similar approach be used to empower our own underclass?

A hopeful thought for this Christmas season.


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