|"Copenhagen Consensus" theme:
Analysis of the actual efforts and their outcome
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Lomborg arranged the first "Copenhagen Consensus" conference in 2004. A main result of that conference was that an imaginary sum of about US$ 50 billion could best be allocated to the following projects: $ 27 billion to prevent the spread of HIV/AIDS, $ 12 billion to alleviate malnutrition (iron deficiency), and $ 13 billion for control and treatment of malaria.
According to Lomborg´s own statements, the Copenhagen Consensus conference 2004 has had some influence on actual spending of aid for the Third World. For instance he claims that it has stimulated the American government to launch the President's Malaria Initiative, a $1.2 billion, five-year plan to fight malaria in 15 of the hardest-hit countries in Africa.
The US government was already the main contributor to the "Global Fund to Fight AIDS, tuberculosis and malaria". From the inception of this fund in 2001 and up to 2007, the US government has donated a total of 2.5 billion dollars to it.
There has been an explosive rise in global funding of efforts against AIDS, from $ 250 million in 1996 to $ 10 billion in 2007. In January 2003 President Bush announced his $15 billion initiative to fight HIV and AIDS in Africa and the Caribbean, known as the President's Emergency Plan for AIDS Relief (PEPFAR). This initiative is rather much in line with the recommendations from Copenhagen Consensus 2004, and thus it is relevant to evaluate the outcome of this initiative.
The Copenhagen Consensus challenge paper by Anne Mills and Sam Shillcutt (link) on communicable diseases claims that by an eight year long effort to fight HIV/AIDS the total number of HIV infections in low and middle income contries during the period 2002-2010 will be reduced by about 66 % - from 45.4 million infections without intervention to just 16.9 million infections with intervention. Interventions deal with condom use, treatment seeking behaviour, age at first sexual intercourse, number of sexual partners, and sharing of potentially infected needles. For such interventions, they calculate a benefit/cost ratio of more than 40.
The American PEPFAR initiative was launched in 2003, with an appropriation of $ 15 billion to be spent over five years. This is about half the amount allocated to stop the spread of HIV/AIDS in the Copenhagen Consensus prioritization. When this is added to other grants from other sources, the total amount spent is about the size recommended in Copenhagen Consensus.
The money from the PEPFAR initiative was spent in 15 focus countries, 12 of them in Africa. An evaluation of the effect of the project in the 12 African countries was published in the spring of 2009 (link). Out of the total sum of $ 18.8 billion that was actually spent, nearly half was spent on anti-retroviral drugs and treatment infrastructure. 2 million people were treated with the drugs. One fifth of the money was spent on prevention programs, of which one third was earmarked for abstinence-only programs. It is claimed that 7 million HIV infections were prevented in the focus countries within the 5 years of the project.
The interesting part of the evaluation is the comparison of the 12 African focus countries with 29 other countries likewise in Africa south of Sahara. Three outcomes were examined: HIV prevalence among adults 15 to 49 years of age, the number of deaths due to HIV or AIDS, and the number of adults living with HIV. During the period 1997-2002 leading up to the start of the PEPFAR project, the average number of AIDS deaths and the average adult prevalence of HIV were both twice as high in the focus countries as in the control countries, and both measures were rapidly rising in all countries. During the project years 2004-2007, there was still a slight increase in AIDS deaths in the control countries. In the focus countries, on the other hand, the yearly number of AIDS deaths declined, when a rise would otherwise have occurred. Altogether, about 1.2 million deaths had been averted as a direct result of the PEPFAR project. This result was so positive that the American congress decided in 2008 to let the project continue and expand.
However, the other parameters studied did not develop favourably. The number of people living with HIV rose steadily in the focus countries, but not in the control countries. This is probably the result of more people with HIV being treated with antiretroviral drugs so that they survive. The prevalence of HIV among adults was initially about twice as high in the focus countries as in the control countries (10 % vs. 5 %). What happened during the period 2004-2007 was simply that the prevalence stabilised at the initial level; it did not drop.
This is in stark contrast with what was anticipated in the Copenhagen Consensus conference. Here it was expected that the prevalence would be reduced by 66 %, whereas the reality is that the prevalence did not drop. Why did reality not live up to expectations?
One major issue is that treatment with anti-retroviral drugs is not very cost effective. Thus, nearly half of the money was used for that measure which was known already to be the least cost effective. Out of the remaining money, only a minor part was used to prevent infections, and furthermore, for religious/ideological reasons, little focus was on increased condom use - which is the most cost effective of all known interventions - and more focus was on abstinence, which is probably less effective.
In summary, the expected benefit of about 40 times the investment - i.e. a benefit of about $ 600 billion from prevention of infection - became an actual benefit of nil. The only measurable benefit was from the least cost effective measure, the drug treatment. Based on the more than US$ 6 billion that PEPFAR had spent on this purpose in the 12 countries by the end of 2007, the researchers estimated the cost of each death averted at $2,450, which is a much lower cost than had been predicted by most experts - partly because the drug had become cheaper. Altogether, reality was very different from what was anticipated in Copenhagen four years earlier - which means that the type of cost-benefit calculations presented there should not be taken to represent anything near reality.
The next issue is malaria. Here, too, the funding has increased since 2004. One of the increased contributions is the American PMI - the President's Malaria Initiative.
A WHO report on the progress in fighting malaria in Africa south of Sahara appeared in 2008 (link). The total amount spent on combating malaria is not known, but the combined funding from the three major external sources (the Global Fund, the World Bank, and PMI) seems to have been 600-700 million dollars annually in recent years. To this must be added the contributions from the local governments, whereby the total probably reaches about 1 billion dollars per year. This is clearly less than what was judged to be necessary in Copenhagen Consensus, and the targets concerning prevention have not been met. Thus, although the target is that 80 % of all African children sleep under insecticide treated nets, the present figures are that only about 25 % of the children do so. This percentage is rising, but is still very far from 80. Only five African countries reported a coverage of indoor spraying sufficient to protect at least 70% of people at risk of malaria. Of African children with fever, 38 % were treated with antimalarial drugs, but only 3% with the recommended drug combination ACT that aims at preventing fast development of resistance in the parasite. In summary, although much is done and the effort is increasing, there is still a long way to go before the effort is sufficient.
Still, one would hope that the increased effort shows off in the mortality statistics. This is clearly so in most countries outside of Africa. During the decade 1997–2006 malaria cases were falling in at least 25 countries, and in 22 of these countries, the number of reported cases fell by 50% or more between 2000 and 2006–2007, in line with the targets. The recorded number of malaria deaths has fallen in Suriname, Cambodia, Laos, Philippines, Thailand and Viet Nam, and these six countries are on course to meet the targets for reductions in malaria mortality by 2010. This is seen as the result of specific interventions.
Within Africa south of Sahara, which already has about 90 % of all malaria deaths, the situation is not so favourable. Among 41 African countries that provided case and death reports over the period 1997–2006, the most persuasive evidence for impact comes from four countries with relatively small populations, good surveillance, and high intervention coverage. They are Eritrea, Rwanda, Sao Tome and Principe, and Zanzibar (part of Tanzania). These four countries/areas reduced the malaria burden by 50% or more between 2000 and 2007.
In other African countries where a high proportion of people have access to antimalarial drugs or insecticidal nets, such as Ethiopia, Gambia, Kenya, Mali, Niger and Togo, routine surveillance data do not yet show, unequivocally, the expected reductions in morbidity and mortality. Either the data are incomplete, or the effects of interventions are small. In southernmost Africa there are positive effects of indoor spraying with insecticides, but apart from that, there are no African countries with large human populations where a positive effect of the interventions can be seen by now. Therefore, one can hardly say that reality agrees with the projections presented in Copenhagen Consensus 2004. Maybe the projected effects will appear, but later than projected. And even so, the effects per effort may be smaller than anticipated, which means that benefit/cost ratios may be smaller than those presented.
The whole idea of Copenhagen Consensus is that money should be allocated to those projects where they do most good. Therefore, it is relevant to analyse if the efforts since 2004 live up to this criterion.
A paper by Denny and Emanuel in 2008 (Journal of American Medical Association 300(17): 2048-2051, link) addresses this question. The paper gives a list of cost-effectivness estimates for a number of interventions against various diseases. As to HIV/AIDS, it is obivous from their list that distribution of condoms is by far the most effective, followed, in order of decreasing effectiveness, by prevention of mother-to-child transmission; voluntary counseling and testing; and anti-retroviral drug treatment. However, what has happened is that the least effective measure, the anti-retroviral drug, has got the largest share of the funding.
Furthermore, HIV/AIDS has got much public interest and hence large funding. Lomborg has contributed to this by giving the effort against HIV/AIDS top priority in the Copenhagen Consensus 2004 list. But there are other diseases that claim more deaths and that could be prevented or cured relatively cheaply. For instance, respiratory infections claim nearly 3 million lives each year. Another 2.2 million die annually from diarrhea, and vaccine-preventable bacterial diseases cost 2.1 million lives per year. For some treatments for some of these diseases, the cost-effectiveness figures are very favourable. This is especially true for an intervention where respiratory diseases in newborns are treated in a community-based case management scheme. Also traditional vaccination against diphtheria, measles, polio etc. is very cost-effective, as is treatment of persons which test positive for tuberculosis.
The intentions behind Copenhagen Consensus - to allocate money to where they do most good - has thus partially failed. Money is allotted to drug treatment of AIDS cases, and, to a smaller extent, to prevention of HIV infection and prevention or treatment of tuberculosis and malaria. But efforts against respiratory and diarrheal diseases and other cost-effective efforts get too little attention and are not funded as much as they should if one wanted to save the maximal number of lives for the minimal amount of money.
The declared purpose of Copenhagen Consensus is to teach politicians to allocate money to where they do most good. This has not really been obtained. With and without the impetus from Copenhagen Consensus, the necessity to spend more money on prevention and cure of diseases in the Third World has increased, and that is good. But simple lists of which measures are most cost-effective could have done just as much to allocate money as effectively as possibly as the more complicated and dubious cost-benefit analyses presented by Lomborg´s team.