The Optimist

Green Shoots in the Killing Fields

Citizens of the Democratic Republic of the Congo believe there's hope for their war-torn country even if no one else does -- and their optimism is starting to get results.

After more than 100 years of abuse, the Democratic Republic of the Congo is surely the most dysfunctional country on the planet. It started the 20th century under Belgium's King Leopold II, who oversaw the deaths of millions through exploitation and disease in what was then his personal fiefdom of the Congo Free State, a tyranny made notorious by Joseph Conrad's Heart of Darkness. Independence in 1960 was accompanied by a vicious civil war and, soon after, the CIA-backed rule of Mobutu Sese Seko, one of the most kleptocratic leaders in world history.

Mobutu's presidency ended in 1997 amid renewed civil conflict, which in the decade that followed killed somewhere between 1.8 million to 5.4 million people (the number is subject to dispute). The social disintegration that accompanied the war has bordered on the medieval. In South Kivu province last year, as many as 40 women were raped every day, and one in 10 of them contracted HIV as a result. Last week, the country was declared the second-worst place in the world to be a woman -- one place behind Afghanistan -- by TrustLaw, an NGO that tracks governance and women's legal rights.

Given that history, it is perhaps unsurprising that, according to data from the late economist Angus Maddison, the country was one of only three in the world to see its economy shrink over the past 40 years (the other two were North Korea and Iraq). National output was $16.7 billion in 1970; it was $16.6 billion in 2008. This occurred while the population climbed from 22 million to 67 million people, leaving income per capita only a third of its level in 1970. Between 1990 and 2007 alone, World Bank data suggests that the proportion of the population living on less than $1 a day -- absolute poverty -- increased from 60 to 71 percent. Today the average income is around 68 cents a day, which means most people are living for a week on the price of one McDonald's Happy Meal. In fact, Maddison's estimates suggest that at no point since 1820 has anywhere in the world been as poor as the Congo has been in the past few years.

So it may be near impossible to believe that the heart of darkness isn't quite as nightmarish as it once was. But over the same 1990 to 2007 period in which poverty was spreading, according to the World Bank, infant mortality rates dropped from 15 percent to 9 percent. That's still horribly high, but it means that a child in present-day Congo has a better chance of surviving than a child in South Korea or Mexico in 1960. Maniema, the province of the country that performed worst in the survey, has an infant mortality rate of 13 percent -- below the overall country average in 1990 and below the levels in Peru and Morocco in 1960. The proportion of underweight children has declined. Maternal mortality has also fallen. Even HIV prevalence has dropped, from 4.2 to 3.4 percent of the population.

In no small part, these improvements are connected to the rollout of basic health services. Recent surveys suggest nearly two-thirds of children in the country are vaccinated against diphtheria, whooping cough, and tetanus, and more than half of all households have an insecticide-treated bed net. More than four out of 10 kids who show symptoms of pneumonia get antibiotics, and nearly the same proportion with symptoms of malaria get antimalarials. Forty years ago, when the average income in the Congo was three times what it is today, those treatment rates were close to zero. Prenatal care coverage increased from 56 to 85 percent of the population between 1990 and 2007, and antiretroviral access rates are climbing as well. This spread of lifesaving technologies and support helps to explain why infant mortality is less than it was in the United States in 1900, even though the average American at the time was 16 times richer (adjusted for inflation) than the average 21st-century Congolese.

And it isn't just health. Education rates are climbing by leaps and bounds. Thirteen million Congolese students were enrolled in school in 2007, and the percentage of primary-age kids in school went from 64 to 84 percent between 2006 and 2008 alone. There is now a considerably higher percentage of children in school in the Congo than there was two decades ago -- or, for that matter, in Kuwait and Honduras as recently as 1980.

Given the state of the economy, these achievements have been managed on a pittance. In 2009, according to the World Bank, the Congo's government budget accounted for about 20 percent of GDP -- about $50 per year per citizen. Health and education together accounted for around $9 per year per person -- less than 0.3 percent of what the U.S. government spends per citizen on health care alone. That meager expenditure, augmented by aid and the limited private resources available to individual citizens, was enough to provide a level of health and schooling considerably better than would be expected by far richer countries only a few years ago.

Part of that success story is explained by the advent of new technologies. For example, the Congo is about to benefit from a new vaccine against pneumonia developed with the support of the Global Alliance for Vaccines and Immunization. But it's also a human success story, one that involves health workers turning up to vaccinate kids and provide health services and teachers showing up to class, even amid some of the worst social conditions on Earth -- people like Denis Mukwege, a gynecologist who founded a hospital in the city of Bukavu to provide care for victims of the Congo's epidemic of sexual violence. (Mukwege, ironically, has just been awarded Belgium's King Baudouin International Development Prize for his work -- named after a direct descendent of Leopold II.) Parents across the country, meanwhile, are prioritizing education for their sons and daughters over the help they could provide in the fields or household, and turning up to get their kids vaccinated.

In short, the signs of hope in the Congo are the result of the country's citizens' own belief that things should be better than they are -- and that they can be. It's a remarkable contrast to the cynicism that has defined the country's colonial overlords, native kleptocrats, and odious warlords for more than a century. And thankfully, the people of the Congo seem to be right. It is all a sign that development can occur even in the absence of well-functioning institutions of governance -- and even during a civil war. That, in turn, is a refutation of the idea that we should wait to improve lives, or focus on sustainable development, until bureaucracies function with clockwork efficiency and the rule of law is universally applied. Poor governance is no reason to deny support to some of the people who need it most.


The Optimist

Through Rose-Colored Corrective Lenses

Poor vision is a major hurdle to getting ahead in the developing world. Fortunately, remedies are cheaper and easier -- and more profitable -- than they've ever been before.

The vast majority of global health problems do not consist so much of finding a cure as delivering one. Improving health in the world's poorest countries requires solutions that are cheap and simple to administer -- and the good news is that these are increasingly available. For example, changing the standard response to diarrhea from saline drips (which require sterile needles and medical staff) to sugar-salt solutions (which require neither) has saved millions of lives that would otherwise have been lost to diseases such as cholera.

Next up may be the scourge of poor sight. There are lots of people who can't read signs, watch TV, or recognize a face across the room without corrective vision. I'm one of the lucky few among them who can afford to do something about it; I have four optometrists within blocks of my office and enough money to buy glasses. But around the world, millions of people who should be able to see clearly are almost blind for lack of corrective treatment. The World Health Organization (WHO) estimates that about 150 million people worldwide who need glasses do not have them. In sub-Saharan Africa, only about 5 percent of people with poor eyesight have glasses. Skilled eye professionals are also extremely rare; Rwanda, a country of 10 million people -- an estimated 1.2 million of whom need eyeglasses -- has just 12 optometrists and ophthalmologists.

On top of eye conditions that can be fixed with glasses, over 20 million people worldwide can't see because of cataracts. Cataract operations are not complex, but they do require a surgeon and a properly equipped hospital. And costs for even a straightforward cataract surgery in the United States range above $3,000 -- or more than 50 times per capita annual health expenditure in Pakistan, for example.

This lack of access exacts a heavy toll on the world's poor. A randomized trial in China suggests that giving glasses to children can have an impact on their performance at school equivalent to an extra half-year in class, which should come as no surprise to any kid who has squinted at the blackboard from the back row of the classroom. Children with poor vision in northeast Brazil are 10 percent more likely to drop out of school and nearly 18 percent more likely to repeat a grade. The WHO estimates the global cost of poor eyesight at $269 billion a year in lost productivity.

Fortunately, innovation in eye-care delivery is reducing the requirements in terms of both financial resources and technical skills needed to correct vision problems worldwide. For example, the Aravind eye hospital network in Southern India has perfected a high-volume, low-cost technique for curing cataract blindness. The approach uses a locally produced replacement lens costing less than $5, which is inserted through a small incision into the eye. A surgeon alternating between two different operating tables can treat 15 cases an hour for less than $15 total (a cost covered for 70 percent of patients by cross-subsidy from the 30 percent of customers who are wealthy enough to pay for it). Some 200,000 cataract surgeries are performed each year by the Aravind network.

Mass-production technologies have slashed the price of glasses as well. China now produces readymade eyeglasses for as little as $2 a pair and made-to-order pairs for $5 to $10 retail. In India, the multinational firm Essilor has funded vans that tour towns and villages offering free eye exams and selling prescription plastic glasses (which cost an average of about $5) and ready-made nonprescription reading glasses (as little as $1), a project that has proved profitable in its pilot stage.

To overcome the shortage of skilled professionals, Kovin Naidoo at the University of KwaZulu-Natal in South Africa is working with community-based health workers to provide simple eye exams, which, combined with cheaper glasses, could considerably increase access to corrective vision. Naidoo's work might be made more straightforward by a new eye-test system developed by the MIT Media Lab, which replaces the traditional eye exam's complex set of corrective lenses and eye chart with a matchbox-size plastic device attached to a cell phone loaded with some simple software. The test takes less than two minutes and doesn't require a skilled practitioner; the snap-on plastic device costs about $1.

Another way of getting around the need for skilled eye-care professionals is "adaptive" eyewear. New lenses filled with silicon oil can be adjusted by the customers themselves to provide corrective vision, and cost about $19 a pair. And a new technology using two lenses which slide across each other to alter focus costs as little as $4, and if production can be scaled up the price could be reduced even further.

It is worth noting, however, that the global vision problem is not simply one of cost and a lack of optometrists. In East Timor, for example, a survey found that 55 percent of rural women would be unwilling to pay even $1 for a pair of glasses. The randomized trial of eyeglasses and education in China found that 30 percent of kids who needed glasses and were offered a free pair refused them; the authors suggest that perhaps their parents were operating under the mistaken view that wearing glasses further damages eyesight. But with marketing approaches that increase the demand for glasses, especially among young people, we can ensure that the whole world can finally see clearly.