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October 21, 2010

How to write the recommendations to a report on almost anything: introducing Friday Formulae

October 21, 2010

An evening with Bill and Melinda Gates and the decade of vaccines: is this the future of aid?

October 21, 2010
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lp-logo283x224On Monday night I joined the besuited masses of the UK development scene to sit at the feet (OK, in a crammed 400 seat lecture theatre) of Bill and Melinda Gates as they promoted the ONE campaign’s ‘Living Proof’ project on effective aid. It was great to hear an optimistic message on aid and development for once, especially when it was laid out brilliantly in front of an audience that included a good number of journos.

But it was also weird, not least because they took an hour to try and convince an audience made up largely of aid workers of the merits of 110mnunDebreworkZewdie02aid – not the toughest ask Bill has faced in his career. In fact it sometimes resembled a viva, as the Gateses strutted their stuff before their peers, ably supported by Dr. Debrework Zewdie (right), deputy director of the Global Fund. And they definitely passed, especially Melinda who managed to combine authority and passion, while stopping just short of cheesy.

The chief object of their praise was the British government – two days before the announcement of its Comprehensive Spending Review (aid implications here), this was a very public endorsement from some pretty big fish of the coalition government’s commitment to increasing aid to 0.7% of GNI by 2013, despite the mayhem taking place in other departments. Andrew Mitchell, Secretary of State for International Development, was in the audience, and the Gateses dropped in on David Cameron to drive home their message. As they stressed business thinking, ‘return on investment’ and the need to increase impact assessment, backed by a blizzard of stats, it became clear just how influential the Gates Foundation has become in terms of the aid discourse both here and in the US.

Their main call was for what they termed a ‘decade of vaccines’: get universal distribution of existing vaccines for polio, measles etc and develop new ones for diseases such as malaria. I was struck by both the can-do optimism and the seductive certainties of the vaccine business – so many vaccines distributed = so many millions of lives saved and made healthy and productive. Inspiring stuff, and free of the messiness, complexity, politics and power struggles that usually characterize development. Just technology riding to the rescue, driven by philanthropy’s cash and willpower. And a stark contrast with the gloom that surrounds other issues like the failure to tackle climate change, or the huge complexity of trying to understand (let alone influence) political change. I was tempted – maybe this is what Big Aid should limit itself to – delivering concrete benefits, keep people alive, and leave the rest to national politics?

And yet. And yet. Inside my policy wonk head a nervous tic of ‘yes buts’ stopped me being completely won over. Bill played fast and loose on correlation v causality – OK, aid undoubtedly helped in countries like South Korea, but did Asia as a whole really take off because of aid (maybe I misheard that bit….)? Where do the effective state systems needed to deliver all these vaccines come from, and are big players like the Global Fund strengthening them or weakening them by setting up parallel systems? Surely, aid should help generate good politics as well as immunize kids, for example by empowering citizens to demand accountability? OK, it’s hard to do and hard to measure and a lot less easy to explain than vaccines, but we need Big Aid to do politics if it is going to work. Bill seemed to imply that the messy stuff was what other donors like DFID should be doing, but the danger is that vaccine-style aid actually crowds out the harder-to-measure activities.

The event was in a fantastic location – the British Science Museum. As I left through the half-lit exhibition halls, I passed lifesize replicas (or the originals, for all I know) of the Lunar Lander, and Stephenson’s Rocket. Science and Progress resplendent –technology is all you need. If only it was that simple.

3 minute Living Proof video here, but if you have an hour and half to kill, you can watch the whole event below (but make a cup of tea while it downloads……)


  1. Nice location. Nice presentation. But you are right to be sceptical. The world is getting better we all agree. If Bill and Melinda set out to show that ‘aid’ is contributing to it then they have failed.

    They used three major illustrations:

    Child mortality rates are not necessarily dropping because of aid. Bill offers no graphs to show greater declines in countries with more aid. Or any proof that aid had anything to do with declines in child mortality.

    Melinda is particularly insistent that smaller families are caused by lower child mortality. She keeps repeating this simplistic argument. Smaller families in countries undergoing demographic transitions are not simply caused by declines in child mortality. Aid has not been very successful in bringing down child mortality but has been enormously successful in bringing family planning methods to poorer countries.

    The decline in polio is partly caused by aid. Its continued persistence may also be caused by aid that funds ineffective campaigns or facilitates movement of people.

  2. I too hear the ‘yes buts’…unfortunately, in both paragraphs. When I first went to Africa, to teach English as a volunteer in 1968, the idea was to raise basic skills so that people could bring themselves out of poverty.

    To my horror in 2004, the conditions I saw in southern Zimbabwe, mirrored the 1968 conditions faithfully.

    Yes, it does appear that politics (and in fact the systems which politics deliver) are what is essential, and I have to wonder if it is the prerogative of BIG AID to ‘do’ this. In fact any progress I’ve seen, and believe me it has been small, has been instigated by the people within.

    One example was of a small community whose dam was repaired by a small grant from an NGO. One of the women said ‘you can go now, poverty no longer lives here.’ They had water to grow their vegetables, and to drink. The problem is if ‘we’ were to look at them, ‘we’ would see half-clothed children, barefoot and worm infested; we would se rubbish everywhere. Our take would be poverty; their’s would not. Who is right?

  3. 2 ‘buts’ about giving such a central place to vaccination:

    1. UNICEF tried this in the 1980s but found it hard to create a financially and organisationally sustainable system to maintain coverage once they stepped away. And of course the point about vaccination is that you have to keep doing it, year in and year out.

    2. Vaccination prevents child deaths, but this means that a given child survives and in many cases is lkely to be exposed to other risks, including big child killers like malaria and diarrhoeal disease, which can’t be vaccinated against. As a result the net impact of vaccination on child survival is less than you might think.

    Of course, these are not arguments against vaccination. They are, however, arguments for the importance of creating a wider financially and organisationally sustainable public health system to wrap around vaccination drives. The Gates approach tends towards a siloisation, although I suppose you could also take the view that their money paying for vaccines frees up other resources to create the wider public health back-up.

    These are old debates, going back at least to the mid-1980s. I wonder how much history Bill and Melinda have been reading?

    Duncan: Thanks Matthew. That’s what I thought until Bill started talking about a vaccine for Rotavirus, one of the main causes of diarrhoea deaths (500,000 a year) – see

  4. I don’t accept the second point made by Matthew Lockwood. According to a quick look at WHO statistics, countries with the worst child (under 5) mortality rates have a rate that is up to about 25% and maybe a quarter of these deaths are in the first month before any vaccinations can have an effect. So in the worst case countries, any child that is saved by a vaccination has a greater than 80% chance of living to beyond 5. If the vaccination saves them and they are already a year old then their chance of dying before 5 is halved again.

    Sure, an improvement to public health services that clears up other causes of death would be great too – lets look for some more philanthopists!

  5. Yes a good post!
    The Rocket is genuine – go back and look further, there you can find why UK pulled itself out of poverty: abundant cheap energy; and maybe why UK is going back there, lack of exhibits on green energy!

  6. I was surprised to discover that in low-income countries, road traffic accidents account for 3.7 percent of deaths, twice as high as deaths due to malaria.

    Who will vaccinate against that?

  7. I think with all their financial input that the Gates’ are putting in that helping at least partially in water, sanitation and hygiene would have more affect than with vaccinations. Bore Holes are more sustainable than vaccines. They are one off investments with a little maintenance whilst vaccines have to be imported from pharmaceutical giants, plus water would cut off so many health problems including to some extent the effects of HIV/AIDS and Malaria.

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