Public Policy vs Health Policy: Does it really make sense to spend billions of dollars to wipe out the few remaining cases of polio?
January 18, 2012
On January 13, India became the latest country to celebrate a year completely polio-free. After more than a century as a global scourge and hundreds of thousands lives lost, polio may now be on the verge of being the second human disease wiped off the face of the Earth — after smallpox, which was eradicated 36 years ago. But the global battle to defeat polio is expensive — and we’re by no means sure of victory. That does raise the question: is it worth it?
In 1952, more than 50,000 kids were paralyzed by a polio outbreak in the United States. Today, the disease is unknown in America — and across much of the rest of the world. In 1981, there were more than 65,000 new cases reported worldwide to the World Health Organization. That number dropped to 1,348 in 2010 and 628 in 2011. That progress has saved as many as five million kids from paralysis worldwide and is thanks to a global effort involving millions of volunteers, health workers, and government officials, as well as the World Health Organization, UNICEF, and the Rotary and Gates Foundations.
Despite this heartening success, getting all the way to eradication is proving immensely hard. In 2010, the majority of polio cases were in countries once free of the virus. In 2011, six countries that had been polio-free the previous year saw the disease come back — although the good news is that incidents were few: only 66 cases between them. Unlike smallpox, most cases of polio don’t show any immediate symptoms, which complicates the response to outbreaks. Moreover, vaccinating against the disease takes repeated doses (India’s polio-free year involved two nationwide programs in 2011, each immunizing 172 million children over five days).
And, of course, global eradication depends crucially on parents being willing to vaccinate their kids in the countries still suffering outbreaks — not least Pakistan and Nigeria. Both countries have faced opposition to vaccination programs on the grounds that they are a Western plot to sterilize local girls. Sadly, these wild conspiracy theories were given an additional patina of credibility last year by the revelation that the CIA used a vaccination program to cover its attempts to get DNA samples from Osama bin Laden’s children in Abbottabad. Perhaps polio eradication will be another victim of the war on terror.
In part because of the considerably greater complexity of the vaccination program, the cost of the polio eradication program is mounting. Over the disease’s last decade in the 1970s, the cost of the global smallpox eradication effort was roughly $330 million. Getting India to zero polio cases last year involved a program that has already cost $2 billion, and the worldwide price tag tops $1 billion each year.
Adding to the uncertainty and the cost, there’s a small risk using the standard oral vaccination –which contains a weakened live version of the virus — that the polio virus actually re-emerges at full strength after a time sitting in the guts of vaccinated kids. So, if we want to be fully sure of wiping out the disease using today’s approaches, even many “polio-free” countries would have to continue vaccinating children for five or ten more years using an injectable inactivated polio vaccine — which is more expensive and complex to administer than the oral vaccine.
Every year, then, we’re putting down $1 billion more on a gamble that we can eradicate the disease — a gamble we’re by no means sure of winning. Meanwhile, the very success of the vaccination campaign to date means that polio just isn’t a major public health threat any more. Consider that the global count of polio cases last year, at 628, equals the number of people who died of malaria in Papua New Guinea in 2008. Worldwide, the mosquito-borne disease kills nearly two thirds of a million people a year, yet the international program to roll back malaria sees funding of only about$1.6 billion a year. That’s led some to suggest it’s time to cut our losses with polio (or declare partial victory) and go on to other scourges. Richard Horton, who edits the British medical journalThe Lancet, has suggested that the polio eradication drive is diverting dollars from other health priorities…
January 18, 2012
A Belgian journalist who interviewed me recently about the European debt crisis asked me whether I believed in the European Project. I replied that I would answer her question—if she would tell me what the European Project actually was. By revealing my doubts, I proved to her that I suffered from the strange kind of mental debility known as Euroskepticism, a condition supposedly compounded of low intelligence and aggressive xenophobia. The low intelligence manifests itself in the patient’s view of European institutions as a gravy train for a transnational nomenklatura, rather than as the beginning of a new, generous, and free-spirited type of postnational identity. The xenophobia manifests itself as a secret desire for conflict and war, the European Union and its predecessors supposedly having been responsible for the avoidance of war on the Continent over the last 65 years.
The journalist then asked whether I thought that nationalism was dangerous. The question implied that the choice before Europe was between the European Union and fascism: that all that stood between us and the ascension to power of new Mussolinis, Francos, and Hitlers were the free lunches of senior Eurocrats. I replied that dangerous forms of nationalism existed, of course, but that in the present circumstances, supranationalism represented by far the greater danger. Not only was such supranationalism undemocratic, for it reflected no widespread demand or sentiment among the population; it also risked provoking the very kind of nationalism against which it was to stand as the bulwark. Further, the breakup of supranational polities in Europe tends to be messy, as history demonstrates.
I was not entirely fair, however, in implying that no one could say what the European Project was. José Manuel Barroso, a fiery Portuguese Maoist student leader who became the preternaturally dull president of the European Commission—perhaps not as great a change as one might suppose, many a revolutionary being a frustrated bureaucrat—once let the cat out of the bag. Asked the same question that the journalist asked me, Barroso responded, “Sometimes I like to compare the European Union as a creation to the organization of empires.” He hastened to add that the E.U. was not a traditional empire. But it is surely the case that an empire in Europe, large, rich, and powerful, would assuage the feelings of a political class frustrated by having inherited a smaller role in world affairs than that of their predecessors, who ruled real empires many times larger than their own countries.
Reflection on the situation in tiny Belgium might introduce an element of doubt into the minds of the most fervent believers in the European Project. Belgium has existed ever since it was cobbled together in 1830; yet in all that time, it has not been able to create a durable national identity. One of its many prime ministers, Yves Leterme, once said that just three things held Belgium together: beer, soccer, and the king. As I write, Belgium has not had a central government for more than 500 days. While I must admit, as an occasional visitor to that country, that the difference between Belgium with and Belgium without a central government is not apparent on casual inspection, this interregnum may take the theory of limited government too far.
The reason that Belgium has lacked a government for so long is that the country is divided into two populations (actually three, but the third is too small to count) with incompatible politics: French-speaking Wallonia and Dutch-speaking Flanders. Belgium is officially bilingual, yet you see not a word of Dutch in Wallonia and not a word of French in Flanders. The division could not be starker if barbed wire separated the two provinces. Only in the capital, Brussels, does one find any concession to bilingualism.
Historical and economic factors deepen the division between the two regions. Wallonia, though it contained a minority of Belgium’s population, long dominated its culture and economy. Even the Flemish upper class spoke French at home, while Dutch was the language of the peasantry; until recently, Belgian schools forbade children from speaking Dutch in class. With the decline of Wallonia’s coal and steel industries and the economic rise of Flanders, however, the pattern of dominance changed. Flanders went from being the poor relation to being the rich one, albeit with something of an inferiority complex. In the process, it started to make large transfer payments to Wallonia, which suffered from comparatively high unemployment. Such payments rarely promote goodwill between groups. Resentment is common among both the donors, who harbor suspicions that the recipients are exploiting them, and the recipients, who indulge in mental contortions to explain their dependency away.
It is no surprise, therefore, that the largest political parties in Flanders are either nationalist or free-market; both philosophies lead to reducing or stopping the transfer payments. It is equally unsurprising that the largest political party in Wallonia is socialist and wants the payments to continue or increase. The Wallonian socialist party’s patronage powers in its territory are almost feudal in nature and extent; the last thing that the party of social change wants is actual change. But neither the Flemish parties nor the Wallonian socialists are strong enough to impose a government on the whole country.
Belgium’s inability to form a central government would not matter so much if the country did not need to reduce its public spending. Though Belgium is the largest per-capita exporter of goods and services in the world and has healthy private savings, it also has a large and growing public debt—nearly 100 percent of GDP—and an annual budget deficit of more than 5 percent. With growth negligible and government bond yields rising in a currency (the euro) that the Belgians cannot inflate, retrenchment is essential, but the Walloons and the Flemish cannot agree on how to do it. The Walloons want higher taxes to maintain the current arrangements; the Flemish want lower taxes and reduced spending to promote long-term growth. The result is a stalemate. Wallonia and Flanders are like a married couple who no longer can live together but find divorce impossible because of difficulties over the settlement.
It happens that the central offices of the E.U. are located in Brussels. Yet the political difficulties of Belgium do not give the European unionists pause for thought—or, if they do pause, they reach a peculiar conclusion: that what has not worked in two centuries in a small area with only two populations will work in a few years in a much larger area with a multitude of populations. It does not occur to the unionists that different countries really are different: not a little bit, but radically, in culture, language, history, traditions, and economies. The term “European” is not meaningless, but whatever content the term may have, it is not sufficient for the formation of a viable polity…
Is Britain more European than it thinks? Britain’s recent disputes with the European Union are part of a long historical narrative but it is not the whole story
January 18, 2012
There is the old joke about British reports of ‘Fog in the Channel – Continent cut off.’ The ‘fog’ is now thicker and perhaps even more hazardous than it was. David Cameron’s veto last December during the Eurozone crisis gave it an unhelpful and familiar ‘Britain versus the EU’ dimension as Europe faced its darkest economic moment since the Great Depression. While Angela Merkel and Nicolas Sarkozy tried to pump blood into the collapsing veins of the euro, Cameron’s demands for City of London safeguards appeared self-centred and anti-communautaire.
The French hit back. Sarkozy told Le Monde: ‘There are clearly now two Europes.’ No code there: there is the EU and there is Britain. Merkel was more emollient, telling the Bundestag that it is ‘beyond doubt that Britain will remain an important partner in the EU’. As long as the euro survives this crisis will be put down to experience, like others in the EU’s past. What Cameron asked for was neither unreasonable nor unexpected to those in the know, it was just that he asked for it undiplomatically and at the last moment. The real fallout from these events is that they reaffirm a damaging and distorted history of Britain and Europe. But there is another story to tell.
Let us first reprise the tired narrative of Britain and Europe. Of the contenders for the title ‘Father of Europe’, a short French economist, planner and statesman, Jean Monnet (1888-1979), stands tall. He laid the foundation stone of the EU after the Second World War and wanted the British in from the beginning. Alongside Charles de Gaulle, Monnet travelled to London amid the drama of June 1940. He took with him a proposal for ‘indissoluble union’ between Britain and France, but the plan fell with Petain’s submission to the Nazis. Preventing future Nazis was in part the stimulus for Monnet to write the Schuman Plan of 1950. Named after Robert Schuman, then the French foreign minister, it called for a coal and steel union in western Europe to neutralise historical enmities. Monnet ensured that the British received an invitation to join, but they demurred. One of Monnet’s compatriots recalled the British saying: ‘You in Europe have been defeated, you have been occupied; that is not our situation.’
When the six Schuman Plan countries – Belgium, France, Germany, Italy, Luxembourg and the Netherlands – built on their success with the creation of the European Economic Community (EEC) in 1957, Britain’s position looked like hubris. The British dismissed the Six’s chances leading up to 1957. Rab Butler, former Chancellor of the Exchequer, even described their plans as ‘archaeological excavations’. Yet in 1961, eating partly digestible humble pie, Harold Macmillan’s government decided that Britain had no alternative but to seek membership. The economic imperative was strong – Britain needed a new sense of purpose and economic growth – but so too was an age-old British strategy: no one nation could be allowed to dominate the Continent. Macmillan warned privately of the danger that, through the EEC, the Germans would revive their power: ‘It is really giving them on a plate what we fought two world wars to prevent.’
Yet it was not a German who dominated Europe as Britain tried to get into the EEC, but a Frenchman. General de Gaulle blocked two British applications to join the Community. In saying ‘non’ to the first in January 1963 he stated that Britain was ‘insular’ and ‘maritime’ and set apart by ‘habits and traditions’. He maintained his position throughout the 1960s. Indeed one reason that Britain could enter the EEC on January 1st, 1973 was that de Gaulle had left office in 1969. At last Britain was European, or so it was hoped by Edward Heath’s government. Horizons of economic revival and political rebirth stretched out, but sadly not for Heath who was a casualty of Britain’s mid-1970s malaise. Part of the country’s identity crisis at that time came from Harold Wilson’s decision to put EEC membership to the public in a historic referendum 18 months after entry; the overwhelming ‘yes’ vote of June 6th, 1975, however, did not end the debate.
This story of British ambivalence towards Europe is well-entrenched in the national mind and also those of EU member states, hence the vituperate tone of recent criticisms of Britain. Like British leaders before him, Cameron has been accused of asking for something, while offering nothing in return. As a former Belgian MP said: ‘You’re either at the table or you’re on the menu.’…
January 18, 2012
This image has been posted with express written permission. This cartoon was originally published at Town Hall.