Why Bill Gates Gets It Wrong

NEW YORK – In his review of Nina Munk’s error-filled and out-of-date book, Bill Gates oddly abandons the rigorous approach to measurement and evaluation that defines his foundation’s invaluable work. He simply accepts Munk’s assertion that the Millennium Villages Project – an ongoing development project across more than 20 African countries – has failed. In fact, it is flourishing.


This credulousness is puzzling. Munk’s book covers only a sliver of the first half of a ten-year project, and only two of 12 villages. And she never “lived for extended periods in the Millennium Villages.” Munk spent an average of around six days per year – around 36 days over six years – actually visiting the villages, and usually at a stretch of 2-3 days. Moreover, she came to the story as a reporter for the magazine Vanity Fair, with no training or experience in public health, agronomy, economics, or African development.

Worse, Munk’s observations frequently seem to have been, at the very least, greatly exaggerated for narrative effect. Does Bill Gates really believe that I advocated specific crops without worrying about whether there was a market for them, or that I failed to consider national taxation in my ongoing advice to government leaders? Moreover, the agricultural strategies and choices in the MVP have been led by African agronomists, some of the very best in Africa – often working hand in hand with Bill’s own agricultural staff in the Alliance for a Green Revolution in Africa (AGRA). 

Bill will be happy to know that the MVP will be properly and professionally evaluated next year – on time at its conclusion (and at the end of the Millennium Development Goals in 2015). The assessment will be based on the very considerable data that have been collected over the past decade, and on extensive new survey data that will be collected in 2015. Moreover, the evaluation will include comparisons with areas surrounding the Millennium Villages. In fact, I hope that the Bill & Melinda Gates Foundation will help to carry out the detailed, independently supervised survey work needed for a full evaluation of this complex project.

Let me provide some more good news, based on the detailed data on community health delivery, morbidity (disease), and mortality that the MVP collects each month. Mortality rates are down sharply in the Millennium Villages. In fact, the current evidence, to be examined in greater detail next year, suggests that the bold goal of reducing under-five mortality rates to below 30 deaths per 1,000 births has been achieved or is within reach by 2015, and at a remarkably low cost to the health system.

Recently, one of the Gates Foundation’s senior staff members visited the Millennium Village site in northern Nigeria. Afterwards, he confirmed to me personally that he and his team were deeply impressed by what they saw of the Millennium Village health system in operation.

So let me take this opportunity to reiterate a challenge that I have posed to Bill. He can pick any district in rural Africa, and our team will work with the local communities using the Millennium Village health approach to reduce the under-five mortality rate to below 30/1,000 – a rate characteristic of many middle-income countries – at an annual health-sector cost of just $60 per person. And we will do it in five years or less. That success, I believe, would help Bill and others to recognize the remarkable value of investing in low-cost rural health systems that follow the design principles of the Millennium Village Project.

Finally, given concerns, shared by Bill, about the MVP’s sustainability and scalability, it is no small matter that host governments are strong advocates of the approach. These governments’ leaders have seen the Millennium Villages day in and day out over almost a decade. They are putting their own money and policies behind expanded implementation of the MVP’s guiding concepts.

For example, Nigeria has used the MVP concepts for national-scale delivery of health and education services in all 774 of the country’s Local Government Areas. Governments across the region have taken over $100 million in financing from the Islamic Development Bank to scale up the MVP concepts themselves. Around a dozen countries are now starting or have approached the Millennium Village Project to help them start their own Millennium Villages. And the Pan African Youth Leadership Network, Africa’s own young people, recently visited the Millennium Village in Senegal, and requested the support of the MVP to expand the Millennium Village Project’s techniques and strategies in their home countries and regions.

This spread of the Millennium Village approach throughout Africa shows that African political and community leaders consider the MVP’s methods, strategies, and systems to be highly useful in combating poverty in rural Africa. Nina Munk’s book is out of date and misses the mark. I invite Bill Gates to visit one or more Millennium Village sites on an upcoming trip to Africa to see first hand why the approach is of such practical interest across the continent.

Jeffrey D. Sachs is Professor of Sustainable Development, Professor of Health Policy and Management, and Director of the Earth Institute at Columbia University. He is also Special Adviser to the United Nations Secretary-General on the Millennium Development Goals.

Copyright: Project Syndicate, 2014.
www.project-syndicate.org

Image credit: africa924 / Shutterstock.com


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The image of an undead brain coming back to live again is the stuff of science fiction. Not just any science fiction, specifically B-grade sci fi. What instantly springs to mind is the black-and-white horrors of films like Fiend Without a Face. Bad acting. Plastic monstrosities. Visible strings. And a spinal cord that, for some reason, is also a tentacle?

But like any good science fiction, it's only a matter of time before some manner of it seeps into our reality. This week's Nature published the findings of researchers who managed to restore function to pigs' brains that were clinically dead. At least, what we once thought of as dead.

What's dead may never die, it seems

The researchers did not hail from House Greyjoy — "What is dead may never die" — but came largely from the Yale School of Medicine. They connected 32 pig brains to a system called BrainEx. BrainEx is an artificial perfusion system — that is, a system that takes over the functions normally regulated by the organ. Think a dialysis machine for the mind. The pigs had been killed four hours earlier at a U.S. Department of Agriculture slaughterhouse; their brains completely removed from the skulls.

BrainEx pumped an experiment solution into the brain that essentially mimic blood flow. It brought oxygen and nutrients to the tissues, giving brain cells the resources to begin many normal functions. The cells began consuming and metabolizing sugars. The brains' immune systems kicked in. Neuron samples could carry an electrical signal. Some brain cells even responded to drugs.

The researchers have managed to keep some brains alive for up to 36 hours, and currently do not know if BrainEx can have sustained the brains longer. "It is conceivable we are just preventing the inevitable, and the brain won't be able to recover," said Nenad Sestan, Yale neuroscientist and the lead researcher.

As a control, other brains received either a fake solution or no solution at all. None revived brain activity and deteriorated as normal.

The researchers hope the technology can enhance our ability to study the brain and its cellular functions. One of the main avenues of such studies would be brain disorders and diseases. This could point the way to developing new of treatments for the likes of brain injuries, Alzheimer's, Huntington's, and neurodegenerative conditions.

"This is an extraordinary and very promising breakthrough for neuroscience. It immediately offers a much better model for studying the human brain, which is extraordinarily important, given the vast amount of human suffering from diseases of the mind [and] brain," Nita Farahany, the bioethicists at the Duke University School of Law who wrote the study's commentary, told National Geographic.

An ethical gray matter

Before anyone gets an Island of Dr. Moreau vibe, it's worth noting that the brains did not approach neural activity anywhere near consciousness.

The BrainEx solution contained chemicals that prevented neurons from firing. To be extra cautious, the researchers also monitored the brains for any such activity and were prepared to administer an anesthetic should they have seen signs of consciousness.

Even so, the research signals a massive debate to come regarding medical ethics and our definition of death.

Most countries define death, clinically speaking, as the irreversible loss of brain or circulatory function. This definition was already at odds with some folk- and value-centric understandings, but where do we go if it becomes possible to reverse clinical death with artificial perfusion?

"This is wild," Jonathan Moreno, a bioethicist at the University of Pennsylvania, told the New York Times. "If ever there was an issue that merited big public deliberation on the ethics of science and medicine, this is one."

One possible consequence involves organ donations. Some European countries require emergency responders to use a process that preserves organs when they cannot resuscitate a person. They continue to pump blood throughout the body, but use a "thoracic aortic occlusion balloon" to prevent that blood from reaching the brain.

The system is already controversial because it raises concerns about what caused the patient's death. But what happens when brain death becomes readily reversible? Stuart Younger, a bioethicist at Case Western Reserve University, told Nature that if BrainEx were to become widely available, it could shrink the pool of eligible donors.

"There's a potential conflict here between the interests of potential donors — who might not even be donors — and people who are waiting for organs," he said.

It will be a while before such experiments go anywhere near human subjects. A more immediate ethical question relates to how such experiments harm animal subjects.

Ethical review boards evaluate research protocols and can reject any that causes undue pain, suffering, or distress. Since dead animals feel no pain, suffer no trauma, they are typically approved as subjects. But how do such boards make a judgement regarding the suffering of a "cellularly active" brain? The distress of a partially alive brain?

The dilemma is unprecedented.

Setting new boundaries

Another science fiction story that comes to mind when discussing this story is, of course, Frankenstein. As Farahany told National Geographic: "It is definitely has [sic] a good science-fiction element to it, and it is restoring cellular function where we previously thought impossible. But to have Frankenstein, you need some degree of consciousness, some 'there' there. [The researchers] did not recover any form of consciousness in this study, and it is still unclear if we ever could. But we are one step closer to that possibility."

She's right. The researchers undertook their research for the betterment of humanity, and we may one day reap some unimaginable medical benefits from it. The ethical questions, however, remain as unsettling as the stories they remind us of.