Is more cash for HIV/AIDS a good thing?

Helen Epstein, a visiting fellow at Princeton’s Center for Health and Well-being, raises this question in a recent op-ed in the LA Times. Picking up a theme she explored in earlier essays (here, here [and see this exchange of letters here and here] and this Virginia Quarterly Review piece here) in the New York Review of Books, she makes the case that in Uganda the explosion of AIDS money is leading to a perversion of incentives, fostering corruption (which we knew had happened) and, making a broader claim, that the money has undermined the country’s national response to HIV/AIDS. This, she suggests, is more for the benefit of the donor community than the country. Here are some choice quotes from her op-ed:

All this was personally depressing to me because I love Uganda. Uganda was the first African country to see a nationwide decline in HIV rates, a success that saved perhaps 1 million lives during the 1990s. There has been much debate about whether this was mainly the result of rigorous abstinence or condom use or (my preferred explanation) pragmatic avoidance of casual sex.
But on a deeper level, what really made the difference was none of these things. Rather, it was something public health experts have no name for. The only way to describe it is a shared sense of humanity, social cohesion, mutual aid and commitment that is impossible to quantify or program. During the 1980s and early 1990s, while many other African countries were ignoring the looming AIDS crisis, hundreds of tiny community-based AIDS groups sprang up throughout Uganda to comfort the sick, care for orphans, help neighbors cope with the consequences of AIDS and open up discussion of sexual behavior. Museveni, whose political party has been deeply implicated in the scandal, had been involved in these campaigns.

Truly well-designed aid programs involve hard, unglamorous work and have very modest goals. They involve close monitoring of simple projects, and they are run by officials who learn quickly from their mistakes and recognize that aid is inevitably political, so they anticipate and address such problems as they arise.

Epstein, explicitly engaging Bill Easterly’s recent book White Man’s Burden, makes the argument that these grandiose aid schemes are doomed to fail. I’m afraid she’s right, but I’m not willing to go there because for all of Uganda’s success, a lot of people died in Uganda and throughout the continent and a lot of people are infected now. I just don’t think a local effort is going to be adequate to address the pandemic. I agree that badly done, this scheme could be very bad for developing a local health care system that is competent to survive the current round of giving. However, a modest approach may consign millions to an earlier death.

Hundreds of thousands of them are enjoying extended life because of their access to drugs, financed in part as a consequence of the big dramatic swing in donor giving including the Global Fund and PEPFAR. This is part of a larger debate that I’ll address in a subsequent post between Jeff Sachs and Easterly about whether or not large-scale foreign assistance can do much good. In a nutshell, I want Sachs to be right but am afraid Easterly might be.

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