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The Economics of Infection

Ebola is a truly frightening disease, with a fatality rate as high as 95 percent (although the death rate in the current outbreak in West Africa is only 55 to 60 percent).

It could get much worse. If Ebola successfully made the jump to a more prosperous, densely populated country like Nigeria, whose citizens travel all over the world, the current 800 recorded deaths could become 8,000, or 80,000, or even more. And the worst of it is that there is no effective vaccine or treatment for Ebola.

Let me rephrase that. There is no approved vaccine or treatment for Ebola. There are candidates, some of which have shown promising results when tested on non-human primates. But they haven’t gone through the full testing process that is necessary before they are approved for human use, because nobody was willing to pay for it.

The normal procedure in the United States, home to more than half of the world’s major drug companies (“Big Pharma”), is that basic research for new drugs may be paid for by government grants or even by private philanthropy (like Bill Gates’s $200 million donation for research on a malaria vaccine), but the work of bringing the drugs to market is left to the commercial companies. All too often, they simply can’t be bothered.

It costs hundreds of millions of dollars to take a drug through the whole approval process and put it on the market. That’s worthwhile if the drug will then sell at a high cost and be used regularly over long periods of time: a drug that fights “rich people’s diseases” like cancer or heart disease, say, or even something like Viagra.

But a one-shot vaccine that would mainly be used by poor Africans will never make a profit, so it is ignored.

Galvanized by the panic over Ebola, the National Institutes of Health in the United States has now scheduled phase one trials of an Ebola vaccine on human subjects for next month. But there are two more phases after that, and the earliest a vaccine could be approved for general use is next July. And even in this emergency, it’s public money, not Big Pharma, that is funding the research.

The problem goes much wider than Ebola and other tropical diseases. It extends, unfortunately, to the antibiotics that vanquished the bacterial infections that were once responsible for about 25 percent of adult deaths.

The last new class of antibiotics, carbapenems, was approved in 1980. Since then, nothing—even though the usefulness of existing antibiotics is rapidly eroding as resistant strains of bacteria emerge.

That’s a big threat, but antibiotics are still not big money-makers, as they are used for relatively short periods of time to fight some specific infection. So no new type of antibiotic has been developed by Big Pharma for more than three decades.

A minimum of 23,000 people in the United States died last year of infections that would once have been easily ended by antibiotics; in the European Union the total was 25,000.

There are some measures that would dramatically slow the spread of antibiotic-resistant bacteria. Far fewer prescriptions should be written for antibiotics, and doctors should be monitored to ensure that they are not over-prescribing. Patients must complete any course of antibiotics that they begin, and report that they have done so. Over-the-counter sales of antibiotics in countries like China and Russia must cease.

Above all, it should be a criminal offence to feed antibiotics to animals just to make them grow faster and bigger. (That is where 80 percent of the antibiotics consumed in the United States go at the moment.) And even when all that has been done, the rise of antibiotic-resistant bacteria will continue, though at a much slower pace. Bacterial resistance is an evolutionary process that can only be slowed, not stopped.

So we desperately need new antibiotics, and there are none forthcoming. Without them, warned Dame Sally Davies, chief medical officer for England, “Modern medicine would quickly go out of the window.”

Almost all surgery, including things as commonplace as caesarian sections and hip replacements, and most cancer treatments as well, involve a significant risk of infection that must be controlled by antibiotics. As Prime Minister Davd Cameron told The Time”: “If we fail to act…we are cast back into the dark ages of medicine, where treatable infections and injuries will kill once again.”

Yet Big Pharma will not fill the gap, for those companies are answerable to their shareholders, not to the public. The case for direct state intervention to finance the development of the vaccines and antibiotics that the commercial sector neglects is overwhelming. And very urgent.

The Population Boom

12 March 2007

The Population Boom

By Gwynne Dyer

You look at the numbers and you think: “That’s impossible.” Uganda had about seven million people at independence in 1962, and in only 45 years it has grown to 30 million. By 2050, just over four more decades, there will be 130 million Ugandans, and it will be the twelfth biggest country in the world, with more people than Russia or Japan. Its population will have increased eighteen-fold in less than ninety years.

Many people think that population growth is no longer a problem, and everybody somehow knows that it is politically incorrect to talk about it. Back in 1968, when Paul Ehrlich terrified everybody with his book “The Population Bomb,” it was seen as the gravest long-term threat facing the human race, but now it scarcely gets a mention even in discussions on climate change — as if the number of people producing and consuming on this planet had no relevance to how great the pressure on the environment is.

True, the population explosion has gone away in large parts of the world, in the sense that most developed countries now have birth-rates well below replacement level (2.1 children per woman), and that the global average, including the developing countries of Asia and South America, is now down to 2.3 children. That’s pretty impressive, given that it was 5.4 children per woman as recently as 1970. But there remains the problem of what you might call “inertial growth.”

My own mother had five children, which was not seen as at all unusual at the time. (There was one year when Newfoundland, my birthplace, beat Guatemala for the honour of having the highest birth-rate in the Americas.) The next generation of our family, by contrast, dropped to 2.0: we five brothers and sisters and our five spouses have had a total of just ten children. But that doesn’t mean that our population boom stopped.

If we had just spawned and died, it would have, but we insisted in living on after our children were born. In fact, we’re all still here, although the first grandchildren are already starting to appear — so where there were once ten of us, there are now twenty-three. It takes two full generations at replacement level before the population finally stabilises.

That accounts for about half of the anticipated population growth in the next forty years, which will raise the total number of people on the planet from 6.5 billion to about nine billion. (In other words, we will be adding as many extra people as the total population of the world back in 1950.) But the other half of the growth comes mainly from Africa, already the poorest continent.

This may explain why it became politically incorrect to talk about population growth around 25 years ago. Nine out of the ten countries in the world with the highest birth-rates are African (the other is Afghanistan), and it seemed uncomfortably like pointing the finger at the victim. But runaway population growth is a big factor in making so many Africans victims, and it doesn’t help to stay silent about it.

Sometimes the steadily worsening ratio of people to resources just causes deepening poverty, as in the case of Nigeria, whose population by 2050 will reach 300 million. That is the same as the current population of the United States, but Nigeria, apart from being virtually without industry, does not have one-tenth of the natural resources of the US. If those 300 million people live at all, they will live very badly.

Often, however, the growing pressure of people on the land leads indirectly to catastrophic wars: Sierra Leone, Liberia, Uganda, Somalia, Congo, Angola and Burundi have all been devastated by chronic, many-sided civil wars, and all seven appear in the top ten birth-rate list. Rwanda, Ethiopia and Mozambique, which have suffered similar ordeals, are just out of the top ten. Africa, which accounted for only eight percent of the world’s population when most of its countries got their independence in the 1960s, will contain almost a quarter of the world’s (much larger) population in 2050.

This will have remarkably little impact on the global problem of climate change, since most Africans will still be very poor and have a very small environmental “footprint.” They will be very poor mainly because their populations are growing three times faster than the average in the rest of the world, and you cannot say that this is nobody’s fault. It is a failure of government.

The reason birth-rates dropped in the rest of the world was that cheap, effective means of contraception became freely available and that child death-rates plummeted. Once women realised that they didn’t have to have many children in order that at least some would survive to adulthood, they took advantage of the contraception and brought the birth-rate down with little urging from above. A few well-run African countries, like South Africa, have succeeded in stabilising their populations in this way. The great majority have not.

Uganda’s birth-rate is seven children per woman, little changed from thirty years ago. Uganda’s president, Yoweri Museveni, believes that his country is under-populated, and told parliament last July: “I am not one of those worried about the population explosion. It is a great resource.” He has done many good things for his country, but this one blind spot could undo them all. And he is far from alone.

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To shorten to 725 words, omit paragraphs 10 and 11. (“This will…havenot”)

International Court (ICC)

7 August 2003

Why We Need an International Criminal Court

By Gwynne Dyer

Plea-bargaining happens in most courts, so nobody was upset last month when former Serbian police officer Darko Mrdja, after a year in the custody of the International Criminal Tribunal for the former Yugoslavia, changed his plea to guilty of having massacred over 200 Croatian and Muslim men in August, 1992. He will probably get a lighter sentence, but the court will save a lot of time, and maybe Mrdja will testify against his former colleagues as well.

In an imperfect world, this sort of corner-cutting can be tolerated, but what are we to make of the haggling that is going on to get indicted war criminal Charles Taylor out of the presidency in Liberia? He wants an amnesty as the price of leaving, and it looks like he’s going to get it.

The United Nations-backed Special Court for Sierra Leone has already lost one of its big fish, Foday Sankoh, the back-country warlord who chopped off hands, arms and legs in a reign of terror that killed 70,000 Sierra Leoneans. Sankoh died of a stroke this year after over two years in custody, but no trial. Now it’s likely to lose Charles Taylor as well.

Taylor trained with Sankoh in Libyan guerilla camps, and even before his own rebel movement came to power in Liberia in 1997, he was in league with Sankoh to keep Sierra Leone in turmoil so that they could jointly loot the country’s rich diamond deposits. The Special Court for Sierra Leone issued a 17-count indictment against Taylor in June, but restoring peace in Liberia means getting Taylor out, and it’s simpler and cheaper to do it with his cooperation. So moves to give him “a safe haven” in Nigeria began in early July.

“Nigeria will not be harassed by any organisation, or by any country, for showing this humanitarian gesture,” said Nigeria’s President Olusegun Obasanjo. He need not worry, for the Special Court in Sierra Leone has little reach beyond that country’s borders: the man who is responsible for around 200,000 deaths in Liberia will probably get away scot-free. And this is why we need the International Criminal Court.

Current attempts to bring genocidal killers to justice around the world are scattered and stumbling. Cambodia has just announced that only the ten most senior surviving Khmer Rouge leaders will stand trial for the slaughter of the killing fields’ that cost 1.7 million lives in the late 70s. Prime Minister Hun Sen, a former Khmer Rouge commander himself, was able to limit the trials to this relative handful, a quarter-century late and before a tame local court, because no established international authority could insist on anything else.

Or look at the US and British attempts to remove Carla Del Ponte as chief prosecutor for the International Criminal Tribunal for Rwanda. The stated reason is because she is too busy as chief prosecutor for former Yugoslavia, but it’s really about stopping her from expanding the indictments beyond members of the former Hutu government to include members of the current Tutsi-led government of Rwanda. Since she serves at the pleasure of the Security Council, the US and Britain may well get their way.

If no permanent and independent body has the authority to deal with this sort of crimes, then it will be politics that decides who is punished and who gets off. The International Criminal Court, which came into formal legal existence on 1 July 2002, was designed to move the world on from that primitive system. But it is under heavy assault by the current US administration, which loathes the very idea of the ICC. Why?

The United States says that it fears that American service personnel engaged in international peacekeeping operations might become victims of nuisance prosecutions brought by the ICC, whose judges it does not control. As UN Secretary-General Kofi Annan recently pointed out, however, no UN peacekeeper of any nationality has ever been accused of a crime “anywhere near the crimes that fall under the jurisdiction of the ICC”: mass rape and mass murder, genocide, even cannibalism. The real US objection is ideological.

The ICC has become an obsession of the Bush administration, which sees all international structures that are beyond Washington’s control as potentially hostile curbs on the exercise of American power. Latterly Washington has even been cutting military aid to poor countries that refuse to sign treaties promising never to hand American personnel over to the ICC.

Yet the ICC is up and running. Its eighteen judges — distinguished jurists from eighteen different countries — were selected last year, and chief prosecutor Luis Moreno Ocampo, a former prosecutor of the Argentine junta, was inaugurated in June. There are two hundred files awaiting investigation (not one of them involving Americans), and the first case brought before the court will probably deal with the horrors committed in the Congo civil war.

It will take time for the ICC to have an impact, because it cannot deal with crimes committed before July, 2002. It will take even more time because of American attempts to sabotage it, but since US hostility is driven by ideology rather than national interest, that could change as soon as the next administration. The goal is to create a single standard and a single authority for dealing with genocide, war crimes, and crimes against humanity when local governments are unable or unwilling to act. Ten years from now we will probably be a lot closer to that goal.

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To shorten to 725 words, omit paragraphs 5 and 7. (“Nigeria…court”; and “Or look…way”)

Ivory Coast

29 September 2002

Ivory Coast: The End of the Great Exception

By Gwynne Dyer

Another African country is sliding over the edge, and this time it’s one of the continent’s few success stories, Ivory Coast. A bloody coup attempt, French and American troops flying in to evacuate trapped whites, a looming civil war: deja vu all over again. Except that Ivory Coast was supposed to be the Great Exception.

To its west are Liberia and Sierra Leone, ravaged by a dozen years of civil wars and mass mutilation of civilians. To the north lie Guinea, Mali and Burkina Fasso, three of the poorest places on earth. To the east is relatively fortunate Ghana, where per capita income has halved since independence but at least there has been no war.

There are few more devastated regions of the planet than West Africa, but Ivory Coast still has shining skyscrapers, good restaurants and fairly reliable electricity — and one of the highest per capita incomes in Africa, right up there with countries like Guatemala and the Philippines. Now, however, the miracle is falling apart.

The man who led Ivory Coast to independence in 1960, Felix Houphouet-Boigny, was a model despot. He had his little follies, like turning his native village, Yamoussoukro, into the capital, but until he died in 1993, the spoils were shared equally and no group felt left out. They surely miss him now.

Houphouet-Boigny’s chosen successor managed to stay in power for six years, though the corruption quickly started to get out of hand and the once-good social services began to rot. The first coup came in 1999, led by General Robert Guei, but he was persuaded to allow free elections the following year — which he lost.

The man who should have won, Alassane Dramane Ouattara, was banned from running on the spurious grounds that some of his ancestors came from Burkina Fasso, but really because his supporters were the Muslims of the north, the country’s biggest single voting block. Instead, the old establishment’s candidate, Laurent Gbagbo, won the election, mainly by appealing to the anti-Muslim sentiments of the Christian south. It was a victory that guaranteed further trouble.

On 19 September President Gbagbo summarily disbanded a military unit that served as bodyguards to General Guei — and rather than lose their jobs, the 700-800 soldiers mutinied. Guei and his family were still quietly at home in Abidjan when a squad of paramilitary gendarmes loyal to Gbagbo arrived there and killed them. Ouattara was targeted by another paramilitary death squad, but managed to escape and found refuge with the French ambassador.

After a day of street-fighting in Abidjan that killed at least 270 people, the mutinous soldiers fled north towards their homes — and their allies seized control of Bouake, the second-biggest city, and other major towns across the north. The Economic Community of West African States (ECOWAS), the regional security organisation, announced on 29 September that it would send troops if necessary, the rebels warned that that would cause years of civil war, and the government promised an all-out assault as soon as foreign troops had rescued their own citizens.

This is the same road that Liberia and Sierra Leone went to Hell on. How did things get so bad so fast?

The conditions for a rapid collapse of Ivory Coast’s prosperity and order were probably always present, but they were held at bay for over thirty years by the careful impartiality of the independence hero and perpetual president, Felix Houphouet-Boigny. It probably helped, too, that he kept a close relationship with France (which meant reliable troops on tap), and hired tens of thousands of French experts as ‘advisers’ (which minimised the opportunities for corruption available to native-born Ivorians).

Once Houphouet-Boigny’s imposing personality was gone, however, all the ethnic and religious rivalries that blight other African countries kicked in. Gaining or holding power became a question of creating ethnically-based coalitions and rewarding your supporters lavishly. Ten years of that, and it’s not just the roads and the schools that are falling apart. The trust and the tolerance that are vital in a multi-ethnic country are exhausted as well, the guns have come out, and the familiar African tragedy begins to unfold once more.

It’s worse in West Africa than elsewhere, because there it’s not just the usual welter of different tribes and languages in a single country. There is also a dividing line that runs right through the middle of all the coastal countries and on across the continent through Chad and Sudan to the Red Sea. South of the line and towards the sea, most people are Christians; inland towards the Sahara, most are Muslims. Half the countries along this line have already had at least one north-south civil war, and Ivory Coast may be next.

At least the countries of the region now understand the danger. “A threat to Ivory Coast is a threat to us all,” said Nigeria’s President Olusegun Obasanjo on Saturday. Nobody with an good alternative would want an intervention by the often thuggish and thieving troops of ECOWAS’s military arm, ECOMOG (when the Nigerian-led force was in Liberia, the locals claimed that it stood for ‘Every Car Or Movable Object Gone’), but nobody in Ivory Coast has a better option. And even if it is saved from the fate of Liberia and Sierra Leone this time round, its time as the Great Exception is gone.

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To shorten to 725 words, omit paragraphs 2 and 12. (“To its…war”; and “It’s worse…next”)