COPENHAGEN — If President Bush and his new team plan to recalibrate foreign aid, they might imagine themselves as ER doctors at a large and chronically overburdened urban hospital. What if they refused to distinguish between patients with stab wounds and those with stubbed toes? If they fast-tracked families who made the most fuss? The approach would waste resources and cost lives. Yet this often seems to be the American way of helping the world's poor.
Millions are affected by diseases, malnutrition, the effects of global warming and unsafe drinking water. Yet the U.S. and other First World nations have addressed these problems haphazardly. Though we would all love to win the war against hunger and malnutrition, end conflicts, stamp out economic and political corruption and halt climate change at the same time, we live with limited resources. And we have a moral obligation to spend each dollar where it will do the most possible good.
Last spring, eight of the world's top economists, including three Nobel Prize winners, met at the Copenhagen Consensus conference to set priorities for global change. The premise was simple: How would you spend $50 billion if the main criterion was bang for the buck? The point was to rank ready-to-implement, cost-efficient solutions to the challenges facing the world.
Some of the experts' conclusions were surprising. Instead of stopping carbon emissions, improve nutrition. Instead of limiting corruption, cut trade barriers. Instead of improving basic health services, target specific diseases such as malaria.
The top priority, however -- stopping the spread of HIV -- surprised no one. Total world spending on AIDS treatment and HIV prevention has tripled since 2001 to $6 billion annually. Yet the disease paralyzes families and communities across much of Asia and Africa and now threatens the Mideast and China. In sub-Saharan Africa, prevention strategies are not reaching young women.
Practical solutions, however, such as promoting condom use and clean needles among at-risk people, are working. The conference participants argued that immediately investing $27 billion to expand these programs could avoid 28 million new HIV infections over the next eight years.
So why isn't it happening? One reason: In the scramble over scarce resources, entrenched political forces and local media promote causes that play well at home -- not those that help the most people at the least cost.
Meanwhile, three projects designed to deal with climate change by reducing carbon emissions were put at the bottom of the effectiveness list by the Copenhagen brainstormers.
Global warming should be addressed, the conference participants decided, but through long-term investments in renewable technology. Programs like the Kyoto Protocol, the 1997 carbon emission-cutting pact the U.S. has refused to ratify, will eventually do some good, but at much too high a cost.
In other problem areas, particularly warfare and education, a lack of research prevented the economists from placing solutions on the list.
The human and economic costs of conflict are enormous. But the solutions to civil war are elusive, and military interventions are often politically anathema. Similarly, experience suggests that it is easy to waste money on ill-conceived educational initiatives. The experts called for more research on schemes to reduce public school fees in developing countries and to provide grants for families who send their children to school.
It's never easy to make tough calls about who lives and who dies, who thrives and who is left to wither. But brave leaders must tell the truth to constituents: We cannot do everything. It's triage time. Get in line.
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The Biggest Bang for the Buck
Who must suffer and who can be saved? A very smart group recommends how to divvy up $50 billion in global fixes.
The numbers stagger: Last year, 5 million people got the disease, and 3 million died. The effects ripple through entire societies. In Botswana, probably the worst-stricken country, the infection rate is as high as 40%. In Thailand, a study found that 13% of children in families with an AIDS sufferer left school early. Labor shortages from AIDS deaths lead families to shift from cash crops to subsistence farming and to cut cultivation. Families dissolve, and sufferers and survivors crowd cities. But there's a solution: programs promoting condom and clean-needle use among groups at high risk for HIV and information to the general public, combined with some anti-retroviral medication. Over the next eight years, such programs could avoid more than 28 million new HIV cases and better the lives of many of the estimated 40 million AIDS sufferers. Cost: $27 billion