The Economist
RICK JOHNSTON carries his “Arsenator” with him whenever he leaves his office at the UnitedNations Children's Fund (UNICEF) in Dhaka to check on the handpumps, standpipes and ringwells ofrural Bangladesh. This device, a sort of portable chemistry set, can detect whether villagegroundwater is laced with dangerous concentrations of arsenic. If it finds its way into a person'sorgans the poison can accumulate, causing black lesions and terminal cancers.Arsenic has contaminated over 90% of the shallow tubewells in Muradnagar, a subdistrict threehours from Dhaka. Drilling deeper is not an option: the low-lying aquifer is too salty. Thehouseholds in this corner of the subdistrict rely instead on a gift from the United NationsFoundation: a $4,000-filtration plant, which can strip arsenic and iron from up to 2,000 litres ofwater a day. A small crowd gathers to watch Mr Johnston mix water from the plant with thechemical reagent in his kit. The Arsenator will take 20 minutes to deliver its verdict.In 1990 more than one person in four lacked access to safewater, according to the United Nations. By 2015 that scandalwill be only half as large—if the world's leaders keep thegrand promises they made at the UN's New Yorkheadquarters in September 2000. The pledges, which alsoinclude halving poverty and hunger, schooling the world'schildren, arresting disease and rescuing mothers and theirinfants from untimely deaths, have been translated intoeight “Millennium Development Goals” (MDGs). July 7th is officially the halfway point between setting the goals andreaching the 2015 deadline.Sadly, the UN family is better at making goals than meetingthem. In 1977 in Mar del Plata, Argentina, the world urgeditself to provide safe water and sanitation for all by the endof the 1980s. In 1990 the UN renewed the call, extendingthe deadline to the end of the century. In 1978 in what isnow Almaty, Kazakhstan, governments promised “health forall” by 2000. In 1990 in Jomtien, Thailand, they called foruniversal primary schooling by 2000, a goal pushed back to2015 ten years later. Kevin Watkins, the lead author of theUN's yearly Human Development Report, worries that thepledges the UN mints so readily may become a “debasedcurrency”. In the summer of 2005, at the height of acampaign to “make poverty history”, only 3% of Britonsthought the world would meet the 2015 goal of halvingpoverty, defined as the proportion of people who live on less than the equivalent of a dollar a day.Such fatalism is as unwarranted as complacency. The world is making unprecedented progressagainst poverty. Thanks to miraculous growth in China and India, the first MDG target should bemet. Almost 32% of people in the developing world lived on less than a dollar a day in 1990. In2004 that figure was 19.2%. It should fall below 16% by 2015 (see chart 2).But if such progress inspires optimism, the goals themselvesprovoke scepticism. They are meant to convert worthyaspirations into quantifiable commitments, against whichgovernments can be judged. But only 57 out of 163developing countries have counted the poor more than oncesince 1990. Ninety-two have not counted them at all.The world has promised to halt the spread of malaria by2015. But the disease's death toll is unknown. To monitor itsfourth and fifth goals, cutting infant and maternal mortality,the UN would like to cull data from death certificates. Butmany places lack hospitals, let alone hospital records. TheUN relies instead on surveys, which net 5,000-30,000 peoplein a country once every five years or so. These ask siblingswhether they have lost any sisters to childbirth. But theseestimates are too vague to track trends over time or tomake meaningful comparisons between countries, the UNlaments.The numerical targets are also arbitrary. They are not a global totting up of what might be doablecountry by country. Far from it. China, for example, had more or less halved poverty from its 1990level by the time that goal was set in 2000. Sub-Saharan Africa, by contrast, will not meet any ofthe goals. They remain too distant even to serve as beacons to steer by.Although the extreme-poverty rate in Africa has fallen from an estimated 46% in 1999 to 41% in2004, that is still way off the 2015 target of 22%. Hunger and malnutrition still gnaw at the region:the proportion of under-fives who are underweight has declined only marginally, from 33% in 1990to 29% in 2005. Despite dramatic gains, Africa will not meet the goal of universal primaryenrolment either; the rate is up from 57% in 1999 to 70% in 2005.Africa lags behind partly because its population is growing so rapidly. In rural areas, mothers are giving birth to at least six children on average, doubling the population every generation. As aresult, Africa's top-line numbers are improving more than its ratios. Millions more African childrenare going to school, but the denominator is also increasing. According to the UN, in 1990 there were237m Africans under 14; today, that figure is 348m, and by 2015 it is expected to top 400m. Whatprice the goal of universal schooling at that pace of population growth?Start where you're ATTYet it is still possible to get things done, even if not at the pace that the MDGs demand. Take Mali,for instance. This landlocked country, straddling the Sahel region and the Sahara desert, should beone of the least promising countries for development on earth. It is ranked third from bottom (in175th place) in the UN's human-development index, just shutting out its neighbour Niger and poorSierra Leone. Yet Western governments and aid agencies, to say nothing of Libya, the IslamicDevelopment Bank and the Chinese, are all flocking to Mali with both great expectations and lots ofmoney.Why has Mali generated so much hope, whereas nearby Nigeria and Guinea, for example, provokemerely exasperation? Mali has a government, led by Amadou Toumani Touré (“ATT” to Malians) thatdevotes most of its limited resources to what it calls the “Struggle against Poverty” rather thensquandering them on the baubles of office. Mr Touré's commitment is acknowledged by Malians,who have just re-elected him for a second term. It has also been rewarded by donors. Mali is one ofonly five African countries to have fully qualified for America's Millennium Challenge Account (MCA),with its stringent criteria for good governance; that alone will bring in $460m over the next fiveyears, a huge amount in a country with a government budget of only about $1.5 billion.How will Mr Touré spend this money? Mali's government has made agriculture and infrastructure apriority. The head of its poverty-reduction programme, Sékouba Diarra, argues that rather thandepending on aid, his government wants to raise growth to lift people out of poverty. With greatermechanisation and irrigation, the country's 3.5m farmers will, he hopes, become self-supporting,growing much more than the traditional crop of cotton. Donors have been persuaded to give largesums to support this; the MCA, for example, is funding a 16,000-hectare (40,000-acre) irrigationproject at Alatona, which represents almost a 20% increase in the country's drought-proof cropland.In a desert country, irrigation is probably the most important anti-poverty tool of all, and the resultscan be seen in the remote villages around the desert town of Timbuktu. In recent years villagershave been shown how to build irrigation canals to capture the flood-waters of the huge Niger river,which winds its way through most of the country. This week, with the rains just about to arrive, thepeople of one of the villages, Adina Koira, are coming to the end of a three-month communal slog tobuild up their 5km of irrigation canals. On the irrigated lands they have been able to grow traditionalcrops such as cotton and rice, as well as new ones such as tomatoes and onions. At the momentthey can buy aid-subsidised fertiliser and seeds to do this.So successful has some of this irrigation work been that thevillagers have even reversed the usual patterns ofimmigration. People are coming back to the villages, fromthe capital Bamako, or from other nearby countries such asCôte d'Ivoire and Niger, to share in the new sense ofendeavour, if not actual prosperity. One man, reflecting theexperience of many villagers of the Sahel, says that withoutthe irrigation schemes “none of us would be here today.”The hope eventually is that Mali, using the waters of theNiger, will become the bread-basket of west Africa. It wouldalso be nice to have better access to European and American markets. But for any of that to happen, Mali needs roads andtransport. The country has excellent beef, for instance. Butas one UN official says, “You can't have the cattle walk2,000km to market—they become skeletons.” During thefour-month rainy season, villages just 20km or 30km apartcan become cut off from trading with each other. Thusdonors such as the European Union and China are buildingroads and the Americans are re-developing the internationalairport.Donors now contribute about a fifth of the government'sbudget. Foreigners are happy to help out because they areconfident that the funds they provide will not be misused.The institutional framework for reducing poverty seemsentrenched and irreversible, whatever happens to ATT. MrDiarra is confident that even Mali will reach the goal ofhalving poverty in the end. Not by 2015, but perhaps by 2025.Goal-hangingSuch incremental progress pleases, but does not satisfy, the custodians of the MDGs, such asJeffrey Sachs, the UN's special adviser and a tireless advocate for the goals. They are reluctant tolower their sights, arguing that the goals are akin to human rights, solemn obligations that brook nocompromise. By this reckoning, the developing world's needs can be counted, the cheapest fixes canbe costed, and the resulting bill can be calculated. All that remains is for the rich world to pick upthe tab, so that a poor country's health and education ministries can get the job done.This MDG-think is seductive. It is a potent mix of inspiration (saving lives and educating minds iseminently doable) and accusation (why, then, is the rich world not doing it?). But this thinking isalso misleading. However laudable, the goals wrongly invite people to think of development as akinto an “engineering problem”, as Lant Pritchett, now of Harvard University, and Michael Woolcock ofthe World Bank have argued. The task is to pour money in one end of the MDG pipeline and thencount the tubewells and school enrolments emerging from the other.Some of the duties of government can indeed be left to the technocrats. Repealing tariffs orpreserving the value of the currency are tasks best handled by “ten smart people”, the two authorspoint out. Mr Sachs was one such person, stopping Bolivia's hyperinflation in its tracks in 1985-86,the triumph that first made his name. In Africa, such monetary mayhem is now confined toZimbabwe. Elsewhere, inflation has fallen from an average of 17% in 2000 to 7% last year.Other tasks, such as laying a road or delivering a measles jab, rely on the efforts of many morepeople. But these legionaries need not exercise much judgment or discretion, and their output (amile of road, a shot in the arm) can be easily counted. Thus immunisation drives and road-buildingcampaigns lend themselves to routinised programmes that can be rolled out and “scaled up”, oftenwith the help of foreign funds. International efforts against measles have helped cut the disease'sdeath toll in Africa from 506,000 in 1999 to 126,000 in 2005.Most of the MDGs, however, do not play to these strengths. If a country is to educate every childand spare its infants and mothers an early death, it must enlist the efforts of thousands of teachers,nurses and midwives, all of whom must exercise care, diligence and judgment. Thatconscientiousness is not easy to buy or import, except in showcase communities such as Mr Sachs'sMillennium Villages, of which there are several very impressive examples in Mali. For these services,the link between spending and results is notoriously weak. Ultimate success depends not so much on field-marshals like Mr Sachs, but on footsoldiers like RitaDana, an auxiliary nurse and midwife in the Bardhaman district of West Bengal, who patientlyexamines over 60 pregnant mothers in a day. They arrive from up to 3km away, complaining ofabdominal pain, vomiting or swollen feet—a possible sign of dangerously high blood pressure. Someof these workers show up even when floodwater is “up to the knee”, says Mohammed Hossain, aconsultant to UNICEF. But perhaps a quarter of the centres, he adds, will not be open when theyshould be.The more qualified the doctor, the more likely he is to takeflight. The district hospital in Matlab, Bangladesh, boasts anoperating table, lamp, oxygen cylinder and anaestheticmachine, all carrying the EU's gift tag. They gleam, partlybecause they are unused. Several surgeons andanaesthetists have been trained, but none so far retained.“Other than holding a gun to their head, doctors do not stayhere,” comments Shams Arifeen, a researcher in theInternational Centre for Diarrhoeal Disease Research,Bangladesh (ICDDR,B). Doubling their pay is not the answer,because they can earn five or ten times as much in privatepractice. Besides, specialists want to educate their childrenin Dhaka, not in Bangladesh's backwaters.One response is to turn the doctor's arts into a routineprogramme. Outside a hut not far from the hospital, a youngwoman examines a child suffering from pneumonia anddiarrhoea, with blood in his stool. Her diagnosis is guided bya flow-chart that leaves little room for discretion. She is one of about 4,500 villagers who have beengiven 11 days' training under a scheme called Integrated Management of Childhood Illness (IMCI).The IMCI protocols are a great leveller: Bangladeshi social workers can adhere to them as faithfullyas qualified Brazilian physicians, and reach similar medical conclusions.Doctors and paramedics pose one set of problems, patients and clients another. The IMCI workerscannot count on everybody taking the advice they offer, for example. Farida Yesmin advises ayoung mother, expecting her fourth child, of the need to rest and avoid lifting heavy pots of water.The mother's neighbour, sticking her nose in through the window, offers a second opinion: worknever did me any harm, she insists.The customer is not always rightVillagers think a labour of three or even four days is normal for a first-born, Ms Yesmin says; a fewwill also blame headaches and convulsions on evil spirits. A study published by the ICDDR,Bprovides an alarming catalogue of such misconceptions. Pregnant women are sometimes told to eatless than normal because an empty stomach supposedly leaves room for the baby to grow. Bytradition, midwives might kick the mother's waist or break snails over her head to speed up thedelivery.Superstition is not the only source of competition. Well-stocked quacks in the private sector areadept at giving people what they want—drugs, principally—if not always what they need. Onegovernment paramedic, his desk standing in the rainwater that leaks through the roof, confessesthat he sometimes prescribes vitamin pills for the sake of it, because his patients do not expect toleave his clinic empty-handed.Efforts to tackle the plight of the poor do not always win their favour. The needy make their ownjudgments about outside schemes to improve their lot. In 1980, for example, the UN proclaimed that the next ten years would be the “sanitation decade”. In India the government set aboutimproving sanitation in villages where people still defecated by rivers and under trees. The need wasglaring: contaminated water was responsible for countless deaths from diarrhoea. The solutionseemed obvious: a toilet with a brick cubicle, squatting slab and two pits. The government set itsbudget and began building.Unfortunately, the villagers themselves had not signed up to the UN's proclamations. They preferredto defecate a prudent distance from the place where they ate and slept. Besides, a walk helped toclear the bowels. So the government's construction programme failed abjectly as a sanitationprogramme. As the only pukka concrete structure in many homes, the toilets were often used forstoring grain, keeping hens or even displaying deities, says Chandi Dey of the Ramakrishna Mission,a charity based in Kolkata.In the late 1980s, his mission and UNICEF realised they could not tackle the sanitation need untilthey first drummed up demand. Songs, slogans and slideshows spread the message. Publicmeetings pressed it home. Mr Dey describes how they would put a drop of faecal matter into a glassof water. When people refused to drink from it, the mission would point out that they imbibed suchwater every day from ponds and rivers where some people defecated, even as others bathed theirbodies and rinsed their mouths.Non-governmental organisations, accustomed to the role of good Samaritans, had to learn the art ofmarketing. They offered people a commission for persuading their neighbours to buy a toilet. Onepaid 13 visits to a potential client before closing the deal. Proceeds from the sales helped meet therunning costs of “rural sanitary marts”, which employed poor people as toilet-masons making arange of affordable models (mosaic or ceramic bowls; bamboo or brick walls; single pits or twinpits). Now, says one mission-member, “It is not a programme, it is a movement.”The government soon latched on to this campaign, adding a small subsidy in 1993-94 and apresidential prize in 2003 for villages and districts that can show they are nirmal or unsullied. InWest Bengal, where it began, more than two-thirds of rural households now have access to a toilet.But some districts still lag. M.N. Roy, a top civil servant, puts this down to the “low equilibrium” ofpoor expectations and apathetic politicians.Parish-pump politicsThe trick is to sharpen the elbows and strengthen the hands of poor people so that they demandwhat they need and get what they demand. For example, a recent report on the MDGs by the WorldBank's Bangladesh office lavishes praise on the efforts of Gonoshasthaya Kendra (GK), a healthcharity, which began life as a battlefield clinic, treating the casualties of Bangladesh's war ofindependence. Born in battle, the group still sees a place for “creative tension” between the poorand the people who are supposed to serve them. Whenever someone dies in a village, it holds apublic post-mortem. The aim is not to blame or indict per se—bare-knuckled confrontation wouldalienate the government—but to remind public servants that someone is watching them, and thatthe negligent will be named and shamed. But is this brand of feisty local politics something donors can cultivate? Aid proposals are nowreplete with mentions of the word “community”. Sceptics argue that donors will conjure up“communities” to fit their projects and their timetables, even if no such organic political unit exists.They also worry that ceding control to the grassroots may simply put aid in the hands of the localmafia.Perhaps all donors can do is pray for a more productive politics to evolve, then support it when itdoes. Mali, for example, has gone further than any other African country in decentralising itsgovernment. In 1991 it had 18 local communes, now it has 702. In many communes the peoplenow actually pay local taxes and can see the tangible results of the money that they hand over in aschool or a health centre. Alexander Newton, the head of USAID in Mali, which helps train the newlayer of local administrators in 155 of the communes, argues that “local management of moneytends to be much better.”Likewise, in Bangladesh, households are often asked to pay something towards the filters that striptheir water of arsenic. These charges are not mean-spirited. They aim instead to turn victims intoproprietors. A financial contribution is proof of a household's commitment to a scheme, which helpsto ensure a filter's upkeep. Halima paid 300 takas ($4.30) for her filter. Now she wouldn't part withit for 5,000.Across the border in West Bengal, villages are going a step further. For each well or pump, they areconvening a water committee. The committees collect dues to pay for regular water-quality tests bylaboratories set up in the sanitary marts. Elsewhere, such committees have not always lasted;everyone would rather someone else paid to maintain their well. But without them, villages willremain forever dependent on outside professionals from the government, UNICEF and the like.After 20 minutes, Mr Johnston's arsenic reading is ready. The test paper has turned an ominousshade of ochre, suggesting arsenic up to four times the allowable limit. He is phlegmatic. The filter'sgranules have probably reached the end of their natural life. Once informed, the company can fix itwithin days, and it takes years of exposure at these concentrations to suffer much harm. But asschoolchildren busily fill their kolshi pitchers with contaminated water, the easy promises of sevenyears ago feel a long way from fulfilment.
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