The Reckoning

Rethinking Africa’s Health, Part 1

makoko slum

A mother navigates her family through waterways in the Makoko slum in Lagos. Venice it ain’t.

Photograph by Pius Utomi Ekpei/AFP/Getty Images

To anyone familiar with the back streets of Dakar or Nairobi—or countless other of sub-Saharan Africa’s mega-cities—a disconnect between the “macro” story and hard-scrabble reality is always jarring. World Bank historical data sets for Nigeria, for instance, paint a very positive story if one confines the examination to the Nigeria country page on the Bank’s website.

·         Primary school enrollment, life expectancy and per capital gross national income all follow an upward trajectory since the 1980s.

·          The percentage of Nigerians living above the poverty line has improved from 43 percent in 1985 to nearly 55 percent today.

·         Where only 30 percent of the rural population had access to a decent water supply in 1990, 43 percent are judged to have it today.

As with statistics that told Europeans and Americans that their respective recessions ended in 2009, however, these numbers can ring rather hollow in African ears.

Float in a makeshift boat through the Lagos Lagoon in the slum district Makoko, for instance, and you confront the scale of this disconnect. Some 90,000 Lagosians live in Makoko, a former fishing village now comprising tens of thousands of jerry-built stilt houses. Waste goes directly into the lagoon, and with the nearest water source a three kilometer paddle away (and costing up to 3p for a 10 liter bucket), too often the lagoon also serves residents’ potable needs. Medical care is virtually nonexistent, and except in severe cases, on a fee-for-services basis.

The “basket case” image is a distorting one, however, and increasingly professionals at the policymaking level, development field workers and AID recipients themselves want this changed. For one thing, it has created a “silo” approach to Africa’s health problems, walling off particular diseases (malaria, HIV-AIDS) at the expense of dull, long-term capacity building that must happen if the continent is to avoid stumbling from one epidemic to another.

If one’s sole window into the continent is the western media, basically you’ll get mostly bad news about African health care, of course. The imperatives of selling newspapers (or attracting clicks) requires a certain degree of drama, and the NGOs and charities that often form the primary sources for this reporting are incentivized to highlight the negative. This is as it should be: They do ‘God’s work,’ in a strictly catholic sense. But frankly it is not nearly the full picture.

Indeed, as I keep saying, clumping the unique and often contradictory trends of sub-Saharan Africa’s 48 countries is statistically nonsensical and risks missing enormously important trends. For instance, the World Bank’s commercial arm, the International Finance Corporation, is helping highlight the investment opportunities in certain African health care sectors, a sector growing quickly and more open than many to foreign investment. Not much ink on that.

Foreign Affairs last week published a deeply interesting article by Thomas Bollyky, a Gates Foundation advisor and former US trade negotiator, marvelous job of squaring these two realities. It’s behind a pay wall, but in summary, Bollyky argues coordinated action to confront communicable crises like HIV-AIDS, malaria or tuberculosis must be part of the world’s approach to global health. But by ignoring far greater, non-communicable problems, he says, we doom Africans to low life expectancies and fail to create the impetus for reform and behavioral changes that could be transformational.

“When most people in developed countries think of the biggest health challenges confronting the developing world, they envision a small boy in a rural, dusty village beset by an exotic parasite or bacterial blight. But increasingly, that image is wrong. Instead, it is the working-age woman living in an urban slum, suffering from diabetes, cervical cancer, or stroke—noncommunicable diseases (NCDs) that once confronted wealthy nations alone,” Bollyky writes.

Charities know that raising money for exotic disease eradication in the west is a good deal easier than, say, funding upgrades to substandard cardiac facilities. Yet the latter is the real win in the long run. Unless you’re a card-carrying member of the late Jesse Helms’ “foreign rat holes” school of development aid, it is blindingly obvious that Africa must be helped to help itself, not kept alive on a drip feed of pennies collected in UNICEF milk cartons.

The epidemics are horrific, of course. But a billion people live on this continent, many of them in countries increasingly able to invest in their own capacities. As western aid drops—and drop it already has since 2008—neither the US nor Europe can afford any longer to allow their hearts to dictate priorities. Time for the brain to take charge.

Part II Tomorrow: The “Silo” Effect