What if we allocated aid $ based on how much damage something does, and whether we know how to fix it?

I usually criticize development wonks who come up with yet another ‘if I ruled the world’ plan for reforming everything without thinking through the issues of politics, power and incentives that will determine which (if any) of their grand schemes gets adopted. But it’s been a hard week, and today I’m taking time out from the grind of political realism to rethink aid policy.

Call it a thought experiment. Suppose we started with a blank sheet of paper, and decided which issues to spend aid money on based on two criteria – a) how much death and destruction does a given issue cause in developing countries, and b) do the rich countries actually know how to reduce the damage? That second bit is important – remember Charles Kenny’s book ‘Getting Better‘, which argues powerfully that since we understand how to improve health and education much better than how to generate jobs and growth, aid should concentrate on the former.

If you followed this exercise, I think you would end up with a radically different aid agenda, with a whole bunch of Cinderella issues coming in from the cold (I’m also taking a break from not mixing metaphors).

Here’s the global death toll (from the new edition of FP2P, c/o indefatigable  number crunching from Richard King).

These are global figures, and I don’t have a breakdown by developed/developing. That would be important on obesity, but on other issues, the majority of impact is clearly in poor countries – alcohol, tobacco and road traffic for example. And they are precisely the areas where the rich countries have lots of experience in reducing the damage. It’s certainly a lot more straightforward than inventing/discovering new vaccines. When researchers put signs in Kenyan minibuses (matatus) urging passengers to criticize reckless driving, injuries and deaths fell by a half (for paper see here).

So how come such subjects are so seldom seen as development issues? Where’s the campaign on booze and fag dumping by large corporations in developing countries? Or international seat belt conventions, backed by technical assistance to help governments ratify and implement? Your thoughts please. Presumably some kind of campaigns exist on all these issues – please send links – but they could be a lot more prominent.

And for the truly wonky/medically inclined here’s a more sophisticated version from the Guardian – Disability Adjusted Life Years, which Claire Melamed and John Appleby reckon could be usefully mainstreamed in development. It shows which causes of global death and disability are up/down from 1990-2010. And if you don’t know what Ischemic or COPD mean, look them up.

Alcohol in Africa – more illegal, but not more deadly

Today is election day in the UK, so there’s a fair chance that politically active people of all stripes will be hitting the bottle in celebration or regret this evening – or just drowning their sorrows at the prospect of weeks of haggling/constitutional crisis over a hung parliament. So spare a thought for the boozers of Africa discussed in last week’s Economist:

“THE Korogocho slum is one of the poorest in Nairobi, Kenya’s teeming capital. Its 120,000 residents occupy a stinking square kilometre by the city rubbish dump. Nearly three-quarters are under 30 years old. Many are alcoholics.

The equivalent of $1 is enough to buy four glasses of illegally brewed chang’aa—and oblivion. Some drink the local special, jet-five, so called because the fermentation of maize and sorghum is sped up with pilfered jet fuel. It can damage the brain. Elsewhere in Nairobi, chang’aa is spiked with embalming fluid from mortuaries.

The name, meaning literally “kill me quick”, is well chosen. This and other methanol-based kickers are sometimes fatal: 10ml of methanol can burn the optic nerve; 30ml can kill. Even without the kicker the brew is impure. The water is filthy with fecal matter. When police recently made some raids, decomposing rats and women’s underwear were found in servings of chang’aa. But the price and the potency are more tempting than the heavily taxed bottles of beer that are the staple of richer Kenyans.

Kenya is not alone. The UN’s World Health Organisation reckons that half of all alcohol drunk in Africa is illegal. Neighbouring Uganda may consume more alcohol per person than any country in the world. Much of this is waragi, a banana gin. Some 100 Ugandans died from toxic waragi in April alone. Botswana, arguably sub-Saharan Africa’s most successful country, serves up laela mmago, meaning “goodbye mum”.

East African Breweries is one of Kenya’s biggest companies and taxpayers. It wants to see illicit chang’aa replaced with a safer commercial version. Yet bringing the price of alcohol down to that of water risks increasing alcoholism and forcing the very poorest into even dodgier booze dens. In any case, it could add other costs: crime, violence to women and children, unsafe sex and bad health. Catholic priests in Korogocho host an Alcoholics Anonymous meeting, but in Kenya, as elsewhere in Africa, state help for recovering alcoholics is rare.

What is clear is that urbanisation is changing the way alcohol is drunk. Illicit brews smooth dealmaking and reconciliation in the countryside. But in the sprawling city slums, where most of Nairobi’s people live, they are more often a cheap way of blotting out a sense of abandonment.”

This reminds me of the gin palaces of Victorian London, when alcoholism was far worse than it is today. The temperance movement then was one of the biggest social movements of its time, and in many poor countries, churches play a similar role today (in Latin America one of the reasons why so many women join the evangelical protestant churches is their success in getting their menfolk to stop boozing).

According to the WHO, 2.5 million people a year die of alcohol-related disease (on a par with HIV/AIDS, and considerably more than malaria): “Globally alcohol consumption has increased in recent decades, with all or most of that increase in developing countries. This increase is often occurring in countries with little tradition of alcohol use on population level and few methods of prevention, control or treatment. The rise in alcohol consumption in developing countries provides ample cause for concern over the possible advent of a matching rise in alcohol-related problems in those regions of the world most at risk.”

Religion or regulation may hold the answer, but this is one ill that economic development doesn’t seem to solve – the burden of alcohol-related death and disease does not appear particularly correlated with income. Russia  and Eastern Europe are the worst affected, followed (to my surprise) by China, Latin America and Central Asia. The Northern half of Africa, Europe and South Asia are actually the least affected. North America, southern Africa, south-east Asia and Australia lie somewhere in between.