3 MYTHSTHAT BLOCK PROGRESS FOR THE POOR
By almost any measure, the world is better than it has ever been. People are living longer, healthier lives. Many nations that were aid recipients are now self-sufficient. You might think that such striking progress would be widely celebrated, but in fact, Melinda and I are struck by how many people think the world is getting worse. The belief that the world can’t solve extreme poverty and disease isn’t just mistaken. It is harmful. That’s why in this year’s letter we take apart some of the myths that slow down the work. The next time you hear these myths, we hope you will do the same.
– Bill Gates
So why is this myth so deeply ingrained?
I’ll get to Africa in a moment, but first let’s look at the broader trend around the world, going back a half-century. Fifty years ago, the world was divided in three: the United States and our Western allies; the Soviet Union and its allies; and everyone else. I was born in 1955 and grew up learning that the so-called First World was well off or “developed.” Most everyone in the First World went to school, and we lived long lives. We weren’t sure what life was like behind the Iron Curtain, but it sounded like a scary place. Then there was the so-called Third World—basically everyone else. As far as we knew, it was filled with people who were poor, didn’t go to school much, and died young. Worse, they were trapped in poverty, with no hope of moving up.
Today, the city is mind-blowingly different. Its air is as clean as Los Angeles’ (which isn’t great, but certainly an improvement from 1987). There are high-rise buildings, new roads, and modern bridges. There are still slums and pockets of poverty, but by and large when I visit there now I think, “Wow, most people who live here are middle-class. What a miracle.”
^ MEXICO CITY 1980, 2011
^ NAIROBI 1969, 2009
^ SHANGHAI 1978, 2012
Here’s another way to see the transition: by counting people instead of countries:
That still leaves more than one billion people in extreme poverty, so it’s not time to celebrate. But it is fair to say that the world has changed so much that the terms “developing countries” and “developed countries” have outlived their usefulness.
Any category that lumps China and the Democratic Republic of Congo together confuses more than it clarifies. Some so-called developing countries have come so far that it’s fair to say they have developed. A handful of failed states are hardly developing at all. Most countries are somewhere in the middle. That’s why it’s more instructive to think about countries as low-, middle-, or high-income. (Some experts even divide middle-income into two sub-categories: lower-middle and upper-middle.)
First, don’t let anyone tell you that Africa is worse off today than it was 50 years ago. Income per person has in fact risen in sub-Saharan Africa over that time, and quite a bit in a few countries. After plummeting during the debt crisis of the 1980s, it has climbed by two thirds since 1998, to nearly $2,200 from just over $1,300. Today, more and more countries are turning toward strong sustained development, and more will follow. Seven of the 10 fastest-growing economies of the past half-decade are in Africa.
Africa has also made big strides in health and education. Since 1960, the life span for women in sub-Saharan Africa has gone up from 41 to 57 years, despite the HIV epidemic. Without HIV it would be 61 years. The percentage of children in school has gone from the low 40s to over 75 percent since 1970. Fewer people are hungry, and more people have good nutrition. If getting enough to eat, going to school, and living longer are measures of a good life, then life is definitely getting better there. These improvements are not the end of the story; they’re the foundation for more progress.
The bottom line: Poor countries are not doomed to stay poor. Some of the so-called developing nations have already developed. Many more are on their way. The nations that are still finding their way are not trying to do something unprecedented. They have good examples to learn from.
But most of them will live in countries that are self-sufficient. Every nation in South America, Asia, and Central America (with the possible exception of Haiti), and most in coastal Africa, will have joined the ranks of today’s middle-income nations. More than 70 percent of countries will have a higher per-person income than China does today. Nearly 90 percent will have a higher income than India does today.
It will be a remarkable achievement. When I was born, most countries in the world were poor. In the next two decades, desperately poor countries will become the exception rather than the rule. Billions of people will have been lifted out of extreme poverty. The idea that this will happen within my lifetime is simply amazing to me.
Some people will say that helping almost every country develop to middle-income status will not solve all the world’s problems and will even exacerbate some. It is true that we’ll need to develop cheaper, cleaner sources of energy to keep all this growth from making the climate and environment worse. We will also need to solve the problems that come with affluence, like higher rates of diabetes. However, as more people are educated, they will contribute to solving these problems. Bringing the development agenda near to completion will do more to improve human lives than anything else we do.
I worry about the myth that aid doesn’t work. It gives political leaders an excuse to try to cut back on it—and that would mean fewer lives are saved, and more time before countries can become self-sufficient.
Many people think that development aid is a large part of rich countries’ budgets, which would mean a lot can be saved by cutting back. When pollsters ask Americans what share of the budget goes to aid, the average response is “25 percent.” When asked how much the government should spend, people tend to say “10 percent.” I suspect you would get similar results in the United Kingdom, Germany, and elsewhere.
Here are the actual numbers. For Norway, the most generous nation in the world, it’s less than 3 percent. For the United States, it’s less than 1 percent.
One percent of the U.S. budget is about $30 billion a year. Of that, roughly $11 billion is spent on health: vaccines, bed nets, family planning, drugs to keep people with HIV alive, and so on. (The other $19 billion goes to things like building schools, roads, and irrigation systems.)
Also remember that healthy children do more than merely survive. They go to school and eventually work, and over time they make their countries more self-sufficient. This is why I say aid is such a bargain.
This graphic shows you a few of the programs supported by aid from the United States and other donors. As you can see, the impact is quite impressive.
One of the most common stories about aid is that some of it gets wasted on corruption. It is true that when health aid is stolen or wasted, it costs lives. We need to root out fraud and squeeze more out of every dollar.
You may have heard about a scandal in Cambodia last year involving a bed net program run by The Global Fund to Fight AIDS, Tuberculosis and Malaria. Cambodian officials were caught taking six-figure kickbacks from contractors. Editorial writers trotted out headlines like “How to waste foreign aid money.” One article mentioned me as someone whose money was being wasted.
There is a double standard at work here. I’ve heard people calling on the government to shut down some aid program if one dollar of corruption is found. On the other hand, four of the past seven governors of Illinois have gone to prison for corruption, and to my knowledge no one has demanded that Illinois schools be shut down or its highways closed.
Melinda and I would not be supporting The Global Fund, or any other program, if the money were being misused in a large-scale way. Malaria deaths have dropped 80 percent in Cambodia since The Global Fund started working there in 2003. The horror stories you hear about—where aid just helps a dictator build a new palace—mostly come from a time when a lot of aid was designed to win allies for the Cold War rather than to improve people’s lives. Since that time, all of the actors have gotten much better at measurement. Particularly in health and agriculture, we can validate the outcomes and know the value we’re getting per dollar spent.
Another argument from critics is that aid holds back normal economic development, keeping countries dependent on generosity from outsiders.
This argument makes several mistakes. First, it lumps different kinds of aid together. It doesn’t differentiate aid that is sent directly to governments from funding that is used for research into new tools like vaccines and seeds. The money America spent in the 1960s to develop more productive crops made Asian and Latin American countries less dependent on us, not more. The money we spend today on a Green Revolution for Africa is helping countries grow more food, making them less dependent as well. Aid is a crucial funding source for these “global public goods” that are key for health and economic growth. That’s why our foundation spends over a third of our grants on developing new tools.
Second, the “aid breeds dependency” argument misses all the countries that have graduated from being aid recipients, and focuses only on the most difficult remaining cases. Here is a quick list of former major recipients that have grown so much that they receive hardly any aid today: Botswana, Morocco, Brazil, Mexico, Chile, Costa Rica, Peru, Thailand, Mauritius, Singapore, and Malaysia. South Korea received enormous amounts of aid after the Korean War, and is now a net donor. China is also a net aid donor and funds a lot of science to help developing countries. India receives 0.09 percent of its GDP in aid, down from 1 percent in 1991.
Even in sub-Saharan Africa, the share of the economy that comes from aid is a third lower now than it was 20 years ago, while the total amount of aid to the region has doubled. There are a few countries like Ethiopia that depend on aid, and while we all—especially Ethiopians themselves—want to get to a point where that is no longer true, I don’t know of any compelling argument that says Ethiopia would be better off with a lot less aid today.
Critics are right to say there is no definitive proof that aid drives economic growth. But you could say the same thing about almost any other factor in the economy. It is very hard to know exactly which investments will spark economic growth, especially in the near term. However, we do know that aid drives improvements in health, agriculture, and infrastructure that correlate strongly with growth in the long run. Health aid saves lives and allows children to develop mentally and physically, which will pay off within a generation. Studies show that these children become healthier adults who work more productively. If you’re arguing against that kind of aid, you’ve got to argue that saving lives doesn’t matter to economic growth, or that saving lives simply doesn’t matter.
- “A vaccination campaign in southern Africa virtually eliminated measles as a killer of children.”
- “An international effort eradicated smallpox worldwide.”
- “A program to control tuberculosis in China cut the number of cases by 40 percent between 1990 and 2000.”
- “A regional program to eliminate polio in Latin America after 1985 has eliminated it as a public health threat in the Americas.”
The last point is worth expanding on. Today there are only three countries left that have never been polio-free: Afghanistan, Pakistan, and Nigeria. Last year the global health community adopted a comprehensive plan aimed at getting the world polio-free by 2018, and dozens of donors stepped up to fund it. Once we get rid of polio, the world will save about $2 billion a year that it now spends fighting the disease.
You can see here just how dramatic this convergence will be:
To get there, the world will need to unite around this goal, from scientists and health workers to donors and recipient countries. If this vision is reflected in the next round of the United Nations’ Millennium Development Goals, it will help get everyone working on this milestone.
Many low- and middle-income countries will develop enough to pay for this convergence themselves. Others will need continued generosity from donors, including investments in health-related R&D. Governments will also have to set the right policies. For example middle-income countries should look at taxing tobacco, and at cutting fossil-fuel subsidies to free up funding for health.
Above all, I hope we can stop discussing whether aid works, and spend more time talking about how it can work better. This is especially important as you move from upstream research on global public goods into the downstream effort of delivering these innovations. Are the recipient countries in charge of figuring out where health clinics should be built and training the workers? Are donors helping local teams build up the expertise they need to put the Western experts out of business? Are the best performers sharing the lessons they’ve learned so other countries can follow suit? This has been a big area of learning for the foundation.
I have believed for a long time that disparities in health are some of the worst inequities in the world—that it is unjust and unacceptable that millions of children die every year from causes that we can prevent or treat. I don’t think a child’s fate should be left to what Warren Buffett calls the “ovarian lottery.” If we hit this goal of convergence, the ovarian lottery for health outcomes will be closed for good.
The fact is that a laissez faire approach to development—letting children die now so they don’t starve later—doesn’t actually work, thank goodness. It may be counterintuitive, but the countries with the most deaths have among the fastest-growing populations in the world. This is because the women in these countries tend to have the most births, too. Scholars debate the precise reasons why, but the correlation between child death and birth rates is strong.
People say saving lives leads to overpopulation.
So, what would you do?
If you look at the graph below of Brazil, you’ll see the same thing: As the child mortality rate declined, so did the birth rate. I’ve also charted the population growth rate, to show that the country’s population grew more slowly as more children survived. If you graphed most South American countries, the lines would look similar.
Because most countries—with exceptions in sub-Saharan Africa and South Asia—have now gone through this transition, the global population is growing more slowly every year. As Hans Rosling, a professor at the Karolinska Institute in Sweden and one of my favorite data geeks, said, “The amount of children in the world today is probably the most there will be! We are entering into the age of the Peak Child!”
Here’s an example: Mothers in Mozambique are 80 times more likely to lose a child than mothers in Portugal, the country that ruled Mozambique until 1975. This appalling aggregate statistic represents a grim reality that individual Mozambican women must confront; they can never be confident their children will live. I’ve spoken to mothers who gave birth to many babies and lost most of them. They tell me all their mourning was worth it, so they could end up with the number of surviving children they wanted.
When children are well-nourished, fully vaccinated, and treated for common illnesses like diarrhea, malaria, and pneumonia, the future gets a lot more predictable. Parents start making decisions based on the reasonable expectation that their children will live.
Death rates are just one of many factors that affect birth rates. For example, women’s empowerment, as measured by age of marriage and level of education, matters a great deal. Girls who marry in their mid-teens tend to start getting pregnant earlier and therefore have more children. They usually drop out of school, which limits their opportunities to learn about their bodies, sex, and reproduction—and to gain other kinds of knowledge that helps them improve their lives. And it’s typically very difficult for adolescent brides to speak up in their marriages about their desire to plan their families. I just traveled to Ethiopia, where I had a long conversation with young brides, most of whom were married at 11 years old. They all talked about wanting a different future for their children, but the information they had about contraceptives was spotty at best, and they knew that when they were forced to leave school their best pathway to opportunity was closed off.
In fact, when girls delay marriage and stay in school, everything changes. In a recent study of 30 developing countries, women with no schooling had three more children on average than women who attended high school. When women are empowered with knowledge and skills, they start to change their minds about the kind of future they want.
Eventually, there’s a bulge of people in their prime working years. This means more of the population is in the workforce and generating economic growth. At the same time, since the number of young children is relatively smaller, the government and parents are able to invest more in each child’s education and health care, which can lead to more economic growth over the long term.
The virtuous cycle is not just development jargon. It’s a phenomenon that millions of poor people understand very well, and it guides their decisions from day to day. I have the privilege of meeting women and men in poor countries who commit the small acts of love and optimism—like going without so they can pay their children’s school fees—that propel this cycle forward. The future they hope for and work hard for is the future I believe in.
Saving lives doesn’t lead to overpopulation. In fact, it’s quite the opposite. Creating societies where people enjoy basic health, relative prosperity, fundamental equality, and access to contraceptives is the only way to secure a sustainable world. We will build a better future for everyone by giving people the freedom and the power to build a better future for themselves and their families.
We hope you will help get the word out on all these myths. Help your friends put the bad news in context. Tell political leaders that you care about saving lives and that you support foreign aid. If you’re looking to donate a few dollars, you should know that organizations working in health and development offer a phenomenal return on your money. The next time you’re in an online forum and someone claims that saving children causes overpopulation, you can explain the facts. You can help bring about a new global belief that every life has equal value.
We all have the chance to create a world where extreme poverty is the exception rather than the rule, and where all children have the same chance to thrive, no matter where they’re born. For those of us who believe in the value of every human life, there isn’t any more inspiring work under way in the world today.