The Optimist

The Eradication Calculation

Does it really make sense to spend billions of dollars to wipe out the few remaining cases of polio?

On January 13, India became the latest country to celebrate a year completely polio-free. After more than a century as a global scourge and hundreds of thousands lives lost, polio may now be on the verge of being the second human disease wiped off the face of the Earth -- after smallpox, which was eradicated 36 years ago. But the global battle to defeat polio is expensive -- and we're by no means sure of victory. That does raise the question: is it worth it?

In 1952, more than 50,000 kids were paralyzed by a polio outbreak in the United States. Today, the disease is unknown in America -- and across much of the rest of the world. In 1981, there were more than 65,000 new cases reported worldwide to the World Health Organization. That number dropped to 1,348 in 2010 and 628 in 2011. That progress has saved as many as five million kids from paralysis worldwide and is thanks to a global effort involving millions of volunteers, health workers, and government officials, as well as the World Health Organization, UNICEF, and the Rotary and Gates Foundations.

Despite this heartening success, getting all the way to eradication is proving immensely hard. In 2010, the majority of polio cases were in countries once free of the virus. In 2011, six countries that had been polio-free the previous year saw the disease come back -- although the good news is that incidents were few: only 66 cases between them. Unlike smallpox, most cases of polio don't show any immediate symptoms, which complicates the response to outbreaks. Moreover, vaccinating against the disease takes repeated doses (India's polio-free year involved two nationwide programs in 2011, each immunizing 172 million children over five days).

And, of course, global eradication depends crucially on parents being willing to vaccinate their kids in the countries still suffering outbreaks -- not least Pakistan and Nigeria. Both countries have faced opposition to vaccination programs on the grounds that they are a Western plot to sterilize local girls. Sadly, these wild conspiracy theories were given an additional patina of credibility last year by the revelation that the CIA used a vaccination program to cover its attempts to get DNA samples from Osama bin Laden's children in Abbottabad. Perhaps polio eradication will be another victim of the war on terror.

In part because of the considerably greater complexity of the vaccination program, the cost of the polio eradication program is mounting. Over the disease's last decade in the 1970s, the cost of the global smallpox eradication effort was roughly $330 million. Getting India to zero polio cases last year involved a program that has already cost $2 billion, and the worldwide price tag tops $1 billion each year.

Adding to the uncertainty and the cost, there's a small risk using the standard oral vaccination --which contains a weakened live version of the virus -- that the polio virus actually re-emerges at full strength after a time sitting in the guts of vaccinated kids. So, if we want to be fully sure of wiping out the disease using today's approaches, even many "polio-free" countries would have to continue vaccinating children for five or ten more years using an injectable inactivated polio vaccine -- which is more expensive and complex to administer than the oral vaccine.

Every year, then, we're putting down $1 billion more on a gamble that we can eradicate the disease -- a gamble we're by no means sure of winning. Meanwhile, the very success of the vaccination campaign to date means that polio just isn't a major public health threat any more. Consider that the global count of polio cases last year, at 628, equals the number of people who died of malaria in Papua New Guinea in 2008. Worldwide, the mosquito-borne disease kills nearly two thirds of a million people a year, yet the international program to roll back malaria sees funding of only about $1.6 billion a year. That's led some to suggest it's time to cut our losses with polio (or declare partial victory) and go on to other scourges. Richard Horton, who edits the British medical journal The Lancet, has suggested that the polio eradication drive is diverting dollars from other health priorities.

Horton has a point. Campaign supporters would have a hard time demonstrating that the quest for global polio eradication is the most cost-effective use of $1 billion a year -- compared to improved vaccination rates for more common diseases like measles, or promotion of breastfeeding, or increasing access to bed nets to reduce the burden of malaria.

But we do know two things: first off, even if it is not theoretically the most cost-effective approach, and even allowing for the risk of failure, the polio eradication program is likely to improve global health at a lower cost than many other health interventions in the developing world already receiving far more in the way of international resources. A study by Dr. Radboud Tebbens in the medical journal Vaccine suggested the polio eradication effort, if successful in the next five years, would save more than eight million children from being paralyzed between 1988 and 2035, along with reducing medical costs and increasing productivity enough to outweigh the cost of the eradication program by $40-$50 billion.  

Of course, if we manage global eradication, we will never again have to spend money on polio vaccination -- or on supporting or burying the disease's victims. Conversely, if the effort to stamp out polio was scaled back, the disease would inevitably spread back into areas currently polio-free. Even campaign skeptics accept the disease would expand again to kill or cripple more than 100,000 children a year.

A second reason to continue the push is that polio eradication would send a powerful message to the world at a time when a little more belief in the power of global cooperation would be a very useful thing. Despite the complexity of the eradication program, and despite all of the poverty and corruption in the countries where polio remains, the campaign has already suggested that when the global community works together it can achieve incredible things.

If a billion-plus dollars seems a lot to spend on symbolism, compare it to the cost of hosting that other symbol of global goodwill: the $14 billion 2012 London Olympic Games. So here's  hoping Pakistan and Nigeria can manage to follow India's lead in 2012, and that the world will be polio-free soon after.


The Optimist

The Haitian Migration

Want to help the hundreds of thousands of Haitians still suffering from the 2010 earthquake? Let some of them into the United States.

As we approach the second anniversary of the devastating Haiti earthquake, which killed around 150,000 people and destroyed much of Port-au-Prince, there has been mixed progress.  About half of the rubble has been cleared (if that sounds slow, consider it took five years to remove far less rubble in Aceh after the 2004 Indian Ocean tsunami). About half a million people are still living in camps in Haiti -- but that is down from closer to 1.5 million two years ago. Meanwhile cholera, introduced by U.N. peacekeeping troops, killed over 7,000 people in the aftermath of the crisis -- the infection rate has abated but the disease remains endemic. 

Progress after a disaster is always slower than hoped.  For all the benefits that the donor community has provided in reconstruction, one reason for the lack of progress is the often snail-like pace of heavily bureaucratized assistance efforts in the chaotic post-catastrophe conditions of weakly governed states.  For example, only about half of the cash promised by donors to Haiti for 2010-2011 had been disbursed by last month -- and the figure for U.S.-given aid is only about 30 percent.  There is still a huge gap between donor disbursement and impact on the ground; a lot of the resources have been disbursed only as far as implementing agencies like NGOs and international agencies, many of whom have yet to spend the cash.

Finally, even when implementing agencies do finally spend that money, much of it will go to pay foreign contractors rather than local people.  According to analysis by the Associated Press, Haitian firms successfully won only 1.6 percent of the value of U.S.-funded disaster recovery contracts issued in 2010. Yes, local firms were subcontractors on many of these contracts, but a large proportion of U.S. funding disbursed to support Haitian reconstruction ended up in the U.S. bank accounts of development contractors. We need more rapid ways to get relief directly to disaster victims, including the hundreds of thousands still suffering in the aftermath of the Haiti quake.

Luckily, we already have one: migration. Immediately after the quake, about 200,000 Haitians living in the United States without proper documents were granted "temporary protected status," which allowed them to work -- and send money home -- without fear of deportation. That single step may be the greatest contribution America has made towards Haiti's reconstruction to date.  That's because the 535,000 Haitian migrants in the United States send home money -- remittances -- worth as much as $2 billion a year.  An early estimate by World Bank economist Dilip Ratha suggested that the temporary protected designation might have been worth as much as $360 million in additional remittances to Haiti in 2010 alone -- that's more than total U.S. aid disbursements to the country in 2010 and 2011.

Beyond being a powerful short-term recovery tool, migration is vital to the long-term development of Haiti as well.  Economist Michael Clemens, my colleague at the Center for Global Development, suggests that four out of five Haitians who have escaped destitution have done so by leaving the country. Meanwhile, the potential benefit of a diaspora for Haiti's future prospects have been repeatedly demonstrated: one need only look at Indians working in Silicon Valley who were key to creating Bangalore's booming IT industry or Africans spending time abroad who are responsible for creating new export industries back home.  Across countries, larger migrant populations lead to greater trade, investment, and learning.

So if the United States is really interested in helping Haiti and other countries get back on track in the aftermath of a natural disaster, it should use migration as a tool for disaster recovery.  And, in addition to the temporary protected status designation, there are two other approaches that can be implemented -- despite the toxic environment for sensible immigration policy on Capitol Hill.

First, the United States has a temporary work visa for low-skilled workers.  The "H-2" program admits about 100,000 migrants for seasonal employment in agriculture and vacation resorts each year.  Haitians are ineligible for the program, however, because the country is not on an approved list maintained by the Department of Homeland Security.  But the administration can add countries to the program list without congressional approval, if the secretary of Homeland Security deems it serves the national interest. Surely fostering recovery in a destitute neighbor counts on that score. 

Michael Clemens estimates that each H-2 worker admitted from Haiti would typically raise their family's income by $19,000 a year -- and that each worker would send as much as 50 percent of their earnings back home. If there were just 2,000 Haitians in the United States under the program in 2012, that would amount to more than $20 million.  That's almost twice the amount that the United States has awarded in contracts to Haitian firms and provided in direct budget support to the Haitian government combined, since the earthquake.

Second, the Department of Homeland Security can selectively grant legal entry to Haitians already approved for a green card -- a permanent residence visa -- on the basis that a family member is a U.S. citizen.  A little more than 112,000 approved Haitians are still on the waiting list, however, because the total number of green cards issued to non-immediate family members is capped worldwide each year.  But there is already a "parole" program for Cubans in similar situations, which allows family members to legally enter the United States and wait for the green card here, rather than in Cuba. The Secretary of Homeland Security is authorized to do exactly the same thing with other countries, and Haiti is a good candidate. Clemens suggests about 16,000 Haitians on the green-card waiting list are spouses or minor children of U.S. green-card holders, for whom the case is particularly compelling -- so let's start with them.

It is worth noting that neither of these proposals would necessarily lead to a larger migrant stock in the United States over the long term. It would simply mean that a few more of the migrants the United States was planning to admit anyway came from Haiti, rather than other countries.  Surely, the desperate situation that Haiti finds itself in, and the powerful boost only a few more migrants would provide to the country's economy, justifies a small reallocation.