Madonna’s little incursion into Africa has failed, while Bill Gates has single-handedly stamped out Polio in India. Well, not quite single-handedly – he had help from the World Health Organization (WHO), and pretty much every major aid-giving nation on the planet (including Australia). It’s a little unfair to compare him with Madonna, even though she never produced a product as flawed as Windows, because he’s an awful lot richer than her, and a little less … unpredictable. But still, the two Sydney Morning Herald articles show a tale of two aid programs. One is a well-thought-out attempt to deliver life improvements to very poor people, and one is a silly and vain attempt to build a few schools. The scope of this achievement in India is really staggering and important – the article says 200,000 cases of paralysis a year have been stopped (which seems a little high to me), and that has huge ramifications for those families who would otherwise have been affected by this cruel and evil disease. I should mention here that I have personal “experience” of polio, because my Father was a victim of the disease in his childhood, and is actually suffering renewed symptoms from the stupid disease now in his dotage. Eradicating this disease as we did smallpox has been a major goal of the international health community for a long time.

The article on Madonna’s efforts paints a picture of an aid program in the old style much favoured by governments 20 years ago – jet in, do something pretty useless at exorbitant cost, don’t even try to make it sustainable after you’re gone, pay kickbacks and bribes rather than do the hard work to establish a viable community effort, and make sure that you feather your own nest while you’re at it (not that Madonna was feathering her own nest – I’m sure she was genuine about the whole thing, but like most stars she seems to have been surrounded by idiots). I imagine Madonna – who seems to be a pretty savvy woman, for all her strange religious delusions – will learn from this and make an effort to improve future projects done in her name. But it’s sad because what she’s trying to achieve here – improved secondary school education for girls – has been identified as a very good way of improving health and reducing inequality (of all kinds) in developing nations. Better-educated girls marry later, have less children, have more children survive, and have better income than their peers, and it’s a worthy effort. Malawi has a 12% prevalence of HIV and, although it has made significant inroads into its child and maternal mortality rates (addressing which is not rocket science), educational improvement will help to further reduce those mortality rates. So 15 million dollars wasted on a school project is a crying shame.

Compare this with Bill Gates’ understanding of this issue, and his approach. In his annual letter, he explains the importance of vaccination in the developing world and makes clear an important link that people in the West often fail to understand: reducing infant mortality reduces population growth. This is because people try to plan for a certain family size, and if they know that infant mortality is a significant risk they have extra children to account for the risk, which in many instances leads to over-shooting the target (while, of course, those whose children die keep producing more children until they reach the target). This overshoot also leads to poverty, since childbirth, the death of a child, and raising surviving children are all expensive tasks. So, if you can reduce infant mortality and the associated disability (as in India with polio) you can reduce family sizes and improve family planning in those countries, which leads to a range of economic and employment improvements in those countries. In Malawi, with a 12% HIV rate, taking women out of the workforce to care for children who have a high chance of dying by the age of 5 is madness, when 12% of the working age population is too sick to work. Infant mortality has not just personal economic consequences, but also plays into the nation’s ability to develop, and development is what these nations need.

Bill Gates also notes that, in addition to being efficient means of reducing population growth and improving economic outcomes, vaccines are a good way to intervene in corrupt nations, because programs like Madonna’s school program attract kickbacks, while a vaccine program has nothing of interest to offer anyone. A training program for a bunch of nursing assistants, and a huge box of drugs with no use to anyone except a baby… not a particularly corruptible program. So it’s a very efficient way of reducing infant mortality compared to, say, building girls’ schools or hospitals. Of course, governments can’t and shouldn’t follow his advice on avoiding kickbacks – a government program can’t be seen to be subverting the order of things in a foreign country, and modern aid programs should, wherever possible, try to confront and reduce corruption rather than avoiding it. But Gates’ point is a good one, in that programs designed to be uninteresting to corrupt authorities are a good idea, and  as a private entity he is able to do whatever he likes – and with remarkable consequences in India.

Since I have started teaching public health and statistics to people from developing nations, the cruelty and unnecessary inequality of the international order has become really clear to me. I always knew about it, of course, but it takes on a more personal and understandable aspect when the people you teach have to take your teachings back to their nation and apply them in the breach. Sometimes it makes me quite angry to consider how different the lives of my students’ patients are, compared to my own. So it’s nice to see someone with the wealth and authority of a man like Gates actually making a genuine effort to address these problems in a constructive and thoughtful way, rather than grandstanding, and genuinely making a difference in the world. So tonight, in honour of his achievements and with an eye to countless Indian kids never having to experience the disability that my Father did, I’m raising a toast to Bill Gates.

But I’m still writing this on a mac…