If you’re not with us, you’re against us

"Only a Sachs deals in absolutes"

This post could also be titled “Taking credit, part deux.” Writing in the Guardian, Jeffrey Sachs considers the impressive reduction in child mortality rates across sub-Saharan Africa.

The critics of foreign aid are wrong. A growing flood of data shows that death rates in many poor countries are falling sharply, and that aid-supported programmes for healthcare delivery have played a key role. Aid works; it saves lives.

For the rest of us who are still burdened with the ability to question, this narrative seems a little too convenient. While the last decade was characterized by a massive increase in health aid to African countries, many of these countries also experienced significant economic growth and improvements in governance and safety. As Charles Kenny pointed out in his book many of these gains in survival may be technological, a result of to interventions which were made readily available. Of course, some of this was due to aid – but the resulting relationship is much more complex than “aid goes up, infant mortality goes down.”

All of this is not to suggest that health aid did not play a role – it almost certainly did – but waving one’s hand and giving all the credit to aid is a dangerous simplification. It also ignores a significant amount of heterogeneity – some countries did better than others, so we really need to start asking ourselves “why?” before we start patting ourselves on the back.

Yet, it isn’t the simplistic narrative that bothers me, it is what comes after: a declaration that aid skeptics are not only completely wrong, but that they could be responsible for the death of children:

Unfortunately, at every step during the past decade – and still today – a chorus of aid sceptics has argued against the needed help. They have repeatedly claimed that aid does not work; that the funds will simply be wasted; that anti-malaria bed nets cannot be given to the poor, since the poor won’t use them; that the poor will not take anti-Aids medicines properly; and so on and so forth. Their attacks have been relentless (I’ve faced my share).

The opponents of aid are not merely wrong. Their vocal antagonism still threatens the funding that is needed to get the job done, to cut child and maternal deaths by enough to meet the MDGs by 2015 in the poorest countries, and to continue after that to ensure that all people everywhere finally have access to basic health services.

Emphasis is mine. While Sachs is probably referring to pundits on the other extreme of the distribution, his rhetoric leaves no room for shades of grey; writing what I just wrote doesn’t make me a cautious optimist, it makes me an aid sceptic.

Then he tries to quietly paint aid sceptics as responsible for the deaths of children. Astonishingly, if you read the sentence in bold carefully sentence carefully, it’s clear that Sachs is putting much more weight on reductions in child and maternal death before 2015 than after. Does Mr. Sachs not care about children of the future? That interpretation might seem a bit unfair to you. What a shame.

Numbers are a dirty business

Celia Dugger, whose articles I still find frustrating, has written about the global decline in child mortality over the past twenty years. Dugger commits a popular sin in journalism: reporting absolute numbers instead of ratios or percentages. Giving absolutes can be intentionally misleading – how often have you seen a headline which reads “greatest number of job losses since 1425?”

Luckily, Karin Grepin jumps in with a detailed discussion of the numbers:

The announcement was that there has been a decline in the number – or level – of child deaths, which I thought was an unusual metric to report. The number of deaths is a function of the number of women, the number of births per woman, and proportion of children that die. When I think child mortality, I think just the last of these components. Fertility has been on the decline and it could very well be that we now have less deaths because there are just less births. But as it turns out, this is not what happened because of a nifty little phenomenon that demographers like to call “population momentum”. Since there are more women alive, we still have more births even with lower fertility. We have actually seen a nearly proportional decline in the actual under 5 mortality rate (deaths per live birth).

Read the rest of Grepin’s discussion of the article on here blog here.

This is also an excellent opportunity to mention Grepin’s working paper on the negative impact of HIV/AIDS targeted funding on the general health sector available here, which is a must-read.