Opinion

EDWARD L. GLAESER

US has an even greater role to play in Africa’s health crisis

Gary Neill for the Boston Globe

AS SUMMER wound down, I e-mailed my closest childhood friend, a distinguished Swedish doctor named Christian Sundberg, to inform him I’d soon be visiting his hometown. He responded that he was “in Sierra Leone at a pediatric emergency hospital in the middle of the biggest Ebola outbreak in recorded history.”

The health care systems in West Africa, the epicenter of the current Ebola crisis, have been crippled by the outbreak. Aid workers like Christian risk their lives every day trying to treat the sick and comfort the dying. Many medical professionals — approximately 375 as of Sept. 23 — have contracted the disease themselves. More than 200 have died.

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The best way we can honor these fearless men and women’s actions is to commit the United States permanently to Africa. As my friend writes, Ebola is “an attack of bioterrorism where the terrorist is Mother Nature.” The United States saw this week that it’s also a disease that can transcend borders. It deserves the same committed fight that America brings to human terrorism.

The continent’s health risks are made worse by the fact that so much of its most impoverished now live in urban areas. Urbanization is the route that leads out of poverty and misgovernment. Yet it is a route filled with risks.

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Viruses, like goods and ideas, move readily across dense city streets. The cities of the West were also once killing fields. Life expectancy for boys in New York City trailed the national average by seven years in 1901. Today, somewhat miraculously, life expectancies in New York are more than two years greater than the national average.

To transform cities from places of contagious death into places of vibrant life, they need infrastructure, human capital, and effective government. President Obama has pledged 3,000 medical workers and up to $750 million in aid to the continent to help in the Ebola fight. But we also need to make long-term investments in less obvious areas like better health education, improved hospitals, and strong democracies — all of which may curb the risk of the next epidemic.

Christian and I grew up in the same building in Manhattan in the 1970s, where his father — an overwhelmingly decent man — was the Swedish representative to the UN Security Council. While his mother’s family had resources, Christian’s disdain for material possessions was almost as great as his emphatic bravery. As a 10-year-old, he regularly misplaced his keys, giving him an excuse for entering his 23d floor apartment by jumping James Bond-style from the building’s roof onto the balcony below.

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That courage was surely tested when his father left New York in 1978 to present his sword as ambassador to the Shah of Iran. When the Islamic revolution followed, Christian had tanks rolling into his living room. Christian escaped Tehran and eventually earned a PhD and a medical degree in Sweden. He came to Boston for a postdoctoral position in cancer research.

He has won fancy awards for his research, but he gradually focused more on clinical medicine and started working for Medicins Sans Frontieres, or Doctors without Borders.

He now treats patients suffering severe malnutrition at a MSF hospital in Sierra Leone’s Bo district called Gondama Health Clinic, which he and his colleagues are trying their best to keep open in a collapsing health care system that was already stretched before the current Ebola outbreak.

He can explain why he does this work better than I can:

“It is heartbreaking to see these children who when you first encounter them, you think, ‘How can they be alive?” On the flip side, there are few things as rewarding as assisting these children and seeing how many of them recover [in your care.]”

In the fight against Ebola, Christian sees the biggest need to be more “boots on the ground” — medical workers to help inform and sensitize the population the nature of the disease, then to isolate and treat the infected.

But, even if the outbreak can be brought under control, its effects will long outlast the current epidemic. For one, Christian believes that the malnutrition situation will be even worse nine months from now. Fear of Ebola has all but stopped farming in the region.

How then can the West most effectively invest in Africa? Start with helping city governments with their most important job: to provide clean water and remove sewage.

Nineteenth century urbanites were slaughtered by cholera epidemics that spread through contaminated water. John Snow, the pioneering epidemiologist, discovered the link between water, human waste, and cholera by studying a map of London marked with deaths from the disease.

Western cities only became healthy when cities invested vast sums in water and sewer infrastructure. Early 20th century American cities and towns were spending more on water than the Federal government was spending on everything except for the post office and the army. Yet, despite the high price tag, the health gains from 20th century American sanitation investments comfortably covered the costs.

Cholera still matters — more than 8,000 died in the recent Haiti outburst — but Ebola is not a water-borne disease. For Ebola, the relevant physical infrastructure is more likely to be health care facilities for containing the disease, like the hospital that the US Army is starting to build in Liberia.

Health rises with education across American cities even more dramatically than health rises with education across American families. Schooling determines the overall level of economic success, the quality of medical care and the basic knowledge of disease in the population. The deadly attacks on medical workers that left eight dead in Guinea last month might not have happened if the role of health professionals was better understood.

Educated doctors are an especially crucial resource, and their ranks have been thinned by deaths from the Ebola outbreak. Since we cannot expect medical programs to train enough African doctors quickly enough, we must continue to rely on outside human capital, like Christian, to fly in and save lives.

But it would be far better if the developed world had a more coherent strategy for rapid response to an epidemic in the developing world. It is far easier to stop an epidemic at early stages, but that requires a supply of trained medical professionals who are ready to parachute in as needed.

MSF does heroic work, but I suspect that only western governments have the strength to fund a permanent organization with the resources to apply overwhelming human capital to a nascent outbreak. We have the military might to respond quickly — and the United States is applying that military might to fight against Ebola — but we should also have the medical might to bring shock-and-awe to a war against a deadly virus.

Good government is the final pillar of healthy cities, and it relates closely to the other two priorities. Without effective government, infrastructure spending can lead to colossal corruption or non-functioning investments or both. And I share Jefferson’s view that good government, especially democratic government, depends on education.

Environmental economist Matthew Kahn’s research shows that the death toll from equivalent natural disasters is much higher in countries with less effective political institutions. Good government reduces fatalities in the short run by marshalling resources effectively, and in the long run, by investing in ways that reduce the risks of natural disaster. Weak governments are unwilling to take unpopular steps to mitigate risks, such as moving squatters from regularly flood plains or banning latrines in dense urban areas. Selfish dictators rarely do much to protect their population against epidemics.

The United States’ anti-entanglement advocates would have the country’s focus exclusively on its own problems, but how is that morally defensibly when the suffering of the world’s poorer nations are so much more severe? A heroic Swedish doctor can bring meaning to life by helping the children of Africa. America can too.

Edward L. Glaeser, a Harvard economist, is director of the Rappaport Institute for Greater Boston.
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