MEDICAL NEWS

& PERSPECTIVES

Jeffrey Sachs, PhD

Ending Extreme Poverty, Improving the Human Condition
M. J. Friedrich JAMA: Those living in extreme pov- also capable of not making the effort
erty are the “poorest of the poor.” How to measure [their numbers], as well.

E
RADICATING EXTREME POVERTY AND many people are believed to be living in JAMA: What are some of the specific
hunger is an ambitious goal, to say this condition? challenges that poor countries face in try-
the least. But this is the aim of the Dr Sachs: The World Bank techni- ing to improve conditions, such as pro-
UN(UnitedNations)MillenniumProject, cally describes extreme poverty as a per- viding primary health services?
a global plan to meet a set of 8 targets to son who lives under $1 a day. In my Dr Sachs: In most of tropical Africa,
improve the human condition. These tar- about 75% of the population lives in vil-
gets, called the Millennium Development lages, in rural areas, as subsistence farm-
Goals (MDGs), include halving, between ers. These communities typically lack so
1990 and 2015, the proportion of people much that is basic—electricity, run-
living on $1 a day. ning water, nearby clinics, public trans-
Bruce Gilbert/The Earth Institute at Columbia University

Economist Jeffrey Sachs, PhD, de- port. The basics used for malaria con-
veloped the plan for the UN Millen- trol, such as bed nets, are lacking. There
nium Project and served as its director may be 5 doctors per 100 000 people—or
and as Special Advisor to the United Na- no doctors at all.
tions Secretary-General, Kofi Annan, The challenges in these places are to
from 2002 to 2006. His plan is being build a basic health structure almost
studied in several villages in 10 Afri- from scratch. This has to be addressed
can countries through the UN Millen- systematically. This challenge of scal-
nium Villages Project, which seeks to ing up basic health services is the core
help people transform their lives challenge of public health.
through tools and interventions that JAMA: What steps can be taken to be-
promote clean water, sanitation and gin scaling up health services?
other essential infrastructure, educa- Jeffrey Sachs, PhD
Dr Sachs: A lot can be done, per-
tion, food production, basic health care, haps surprisingly. First, it’s possible to
and environmental sustainability. opinion, a better definition is the in- build clinics at very low cost; physical
Sachs has served as an international ability to meet basic needs, such construction is simply not a problem.
economic advisor throughout the world as adequate nutrition, access to safe wa- Getting the drug supplies for the basic
and has helped address the economic, ter, access to basic education, having medicines—the antibiotics, the anti-
political, environmental, and social a livelihood that can generate an in- malarials—is really not a problem if we
challenges of some of the poorest re- come to meet these basic needs, and ac- put our mind to it, and some coun-
gions, work that he detailed in his best- cess to primary health services. By either tries have been able to do a wonderful
selling book, The End of Poverty. He is definition about 1 billion people live in job in a short period of time.
currently the director of Columbia Uni- extreme poverty. Often a significant number of
versity’s Earth Institute, which de- This number, determined mainly nurses and post–secondary-trained
scribes its mission as helping to “achieve by household survey, is a pretty rough clinical officers are available who can
sustainable development primarily by estimate. It’s an area where a major do a tremendous amount of things to
expanding the world’s understanding effort could and should be made, but treat the basic disease conditions,
of Earth as one integrated system.” of course this is not the only area meaning that more doctors aren’t
In a recent interview with JAMA, where we underinvest in the poor. required. We can train community
Sachs discussed his thoughts on these When the world is capable of leaving health workers—meaning 1 year of
issues and the progress being made millions of people to die for lack of training after secondary school—to
toward eradicating poverty. access to the most basic things, it’s reach out to households to monitor,
©2007 American Medical Association. All rights reserved. (Reprinted) JAMA, October 24/31, 2007—Vol 298, No. 16 1849

Downloaded from www.jama.com at Harvard University, on January 7, 2008

 MEDICAL NEWS & PERSPECTIVES
to help households get to clinics or lo-
cal hospitals. This can make a phenom-
enal difference.
We also now have cell phone cover-
age, wireless Internet coverage, and the
potential for transport to create an
emergency response system. This is
something I’m trying to promote in
the villages in Africa where we’re work-
ing. We have connectivity and com-
munications that make it possible—
even in a very poor setting—to create
an emergency response and referral
system from a local clinic to a hos-
pital.
If we can bring these powerful tech-
nologies to bear they can make a very
large difference. It still won’t be the
comprehensive quality health system
one would like, but it can sharply re-
duce the enormous disease burden.
In addition, there is a mass chemo-
therapy approach being introduced in
a number of countries to treat or pre-
vent tropical parasites such as schisto-
somiasis. Drug companies are ready
to partner with the poorest countries
to bring down the burden of these
parasites.
JAMA: Can you describe 1 or 2 ex-
amples of successes in which a region
adopted a program to improve health?
Dr Sachs: In low-income settings, a
great deal of the disease burden re-
sults from a small number of condi-
tions—infection, undernourishment,
and unsafe childbirth—for both the
mother and the neonate. Countries that
have introduced primary health care to
address these 3 main categories of dis-
ease burden have been able to do very
well.
Campaigns of immunization, con-
trol of vector-borne diseases like ma-
laria, fluoridation, iodinization of salt,
vitamin A, deworming, and school feed-
ing programs are all examples of basic
interventions that can be applied on a
population scale that can dramatically
reduce the burden of disease.
Throughout the Americas there have
been big successes. These countries are
not utterly impoverished and the gov-
ernment has been able to afford to in-
troduce basic primary health care. The
1850 JAMA, October 24/31, 2007—Vol 298, No. 16 (Reprinted)
Downloaded from www.jama.com at Harvard University, on January 7, 2008
results are astounding. The mortality
rates of children under the age of 5 years
can come down from 150 or 200 deaths
per 1000 to 20 to 30 in a relatively short
period of time.
Successes have been widespread in
Asia and Latin America and other
parts of the developing world, with
the really crucial exception being sub-
Saharan Africa and war-torn places
like Afghanistan and Iraq, which
stand out as having absolutely horren-
dous rates of mortality still—not only
because of the violence, but because
of the complete breakdown of public
health systems.
JAMA: Can you provide an example of
a failed health program that taught an im-
portant lesson—one that didn’t take off
but that you learned something from?
Dr Sachs: There are a couple differ-
ent kinds of lessons. One is that rising
incomes don’t necessarily address
health conditions. Simply being aware
of the problem isn’t enough. What is
needed are specific targeted interven-
tions, clinics and hospitals. So many
lower-middle–income countries such as
those in Central America that have pub-
lic health systems still have high ma-
ternal mortality rates because the sys-
tem hasn’t made the effort to improve
the safety of birth.
Another kind of failure is that of
rich countries that fail to recognize
what can be done to save lives and
improve health conditions among the
poor. The most glaring failure is
malaria, with about half a billion
clinical cases and between 1 million
and 3 million deaths each year.
Malaria is largely preventable by
simple technologies such as insecticide-
treated bed nets and treatable by ap-
propriate first-line medicines. Yet in
many cases, the medicines don’t get to
the children in time and they die. The
US championed what’s called social
marketing of bed nets, meaning that the
bed nets are sold at discounted prices.
Although only a dollar or two, many
people simply can’t afford this.
This is perhaps the most dramatic ex-
ample of where we’ve failed miserably
to act with some basic decency to ad-
©2007 American Medical Association. All rights reserved.
dress the problem. It’s a shocking part
of modern neglect that I hope is com-
ing to an end.
JAMA: How do you evaluate and mea-
sure the success of programs in the face
of variables such as unexpected politi-
cal, environmental, and medical events?
Dr Sachs: Often evaluation and data
collection and feedback are simply not
built appropriately into these systems.
And yet with the advent of the Inter-
net and cell phones and computer serv-
ers that can automatically register pub-
lic health information from community
health workers, we should be able to
do a much better job of monitoring dis-
ease surveillance and evaluation of
programs.
In our own work in Millennium Vil-
lages, we weren’t collecting much of the
critical information needed to ensure
properly functioning health care—we
were building clinics and getting train-
ing going and so forth. But now we’re
getting reliable vital statistics informa-
tion month by month and will pursue
that in much greater detail.
The information systems we have can
be used not only to evaluate the pro-
grams but to help the health system to
function. These technologies are go-
ing to prove to be incredibly powerful
in this area and in many other areas of
development.
JAMA: Money is a big issue. You’ve
talked about a global compact between
rich and poor countries—the responsi-
bility of rich countries to contribute mon-
etary assistance and the responsibility of
poor countries to be ready for change. Can
you comment on this?
Dr Sachs: Many countries already
have clear, ambitious programs for de-
velopment. Most of these countries,
however, are too poor to finance the in-
vestments on their own.
This financial gap is where we come
in. Malawi, for example, can maybe
spend $8 to $10 per capita on its health
system. But it’s not going to reach the
$40 to $50 needed for an even rudi-
mentary system. Malawi will get out of
poverty over time, but not all at once
and not if these disease burdens re-
main as high as they are.
 MEDICAL NEWS & PERSPECTIVES

I don’t accept that we don’t have the being as well as for the lives that we Dr Sachs: The first thing I say is stop
money to do it. We can decide to allo- save. criticizing and come up with solutions.
cate a tenth of 1% of our income to JAMA: You believe that extreme pov- The tools for change are very pow-
make it possible to save millions of lives erty can be eradicated by 2025. How do erful. We just have to decide to use
every year—and I believe firmly that we you respond to critics who say you’re too them against these problems that de-
should be doing that for our own well- optimistic? serve our attention. 䊐

Food Insecurity Harms Health, Well-being

of Millions in the United States
Tracy Hampton, PhD rience malnutrition. Medication adher- betes require special diets, and yet the
ence may not be a high priority for pa- ability to be consistent with those spe-

N
UTRITION IS PARAMOUNT TO tients who must focus their resources cial diets was compromised by food in-
health and survival, yet many in- on obtaining access to an adequate food security,” said Mark Nord, PhD, of the
dividuals and families struggle to supply. And, as research is beginning Food Assistance Branch at the Eco-
maintain a healthy diet, especially those to explain, access to food can affect the nomic Research Service of the USDA.
with low incomes. Nearly 12.6 million development and prevention of medi- Food insecurity also has been linked
households (11%) in the United States cal conditions and diseases. to overweight and obesity, particu-
were “food insecure” at times during These effects can be especially pro- larly among women (Townsend MS et
2005, meaning they were without the re- found in children. When children live al. J Nutr. 2001;131[6]:1738-1745;
sources to feed themselves enough or in food-insecure households, their Wilde PE and Peterman JN. J Nutr.
were unable for economic reasons to pur- health status may be impaired, mak- 2006;136[5]:1395-1400). This appar-
chase healthful foods, according to the ing them less able to resist illness and ent paradox may be explained by the
US Department of Agriculture (USDA). more likely to become hospitalized (Ca- fact that high-calorie, processed foods
Most, but not all, of the world’s un- sey PH et al. J Nutr. 2004;134[6]:1432- often are less expensive than fresh, per-
dernourished people live outside the 1438). Also, poverty and its associ- ishable foods such as fruits, veg-
United States, in poor countries. Accord- ated poor nutrition can increase risks etables, and low-fat dairy products.
ing to a report by the Food and Agricul- of stunting, inadequate cognitive stimu- “One of the first food groups that’s cut
tural Organization of the United Na- lation, iodine deficiency, and iron de- out of an impoverished person’s diet is
tions, in 2001 to 2003, 820 million of the ficiency anemia (Walker SP et al. Lan- produce,” explained David H. Holben,
854 million undernourished people cet. 2007;369[9556]:145-157). PhD, RD, of the School of Human and
worldwide were in developing coun- In adults, food insecurity has been Consumer Sciences, at Ohio Univer-
tries, 25 million in the transitional coun- associated with type 2 diabetes (Selig- sity, in Athens. “Generally speaking, they
tries, and 9 million in the industrialized man HK et al. J Gen Intern Med. 2007; often choose high-fat, high-sugar, low-
countries (http://www.fao.org/docrep 22[7]:1018-1023). “Patients with dia- cost foods that taste good,” he added. Re-
/009/a0750e/a0750e00.htm). In the
United States, food insecurity tends to be
higher among households with in-
comes near or below the federal pov-
erty line, households headed by single Although most of
women with children, and black and His- the world’s
undernourished
panic households. people live in poor
Experts are working to decrease the countries, food
rates of food insecurity and to im- insecurity—lacking
prove the health of individuals who do the resources to buy
Tom Hahn/iStockphoto.com

enough food or to
not have access to nutritious foods. purchase the
appropriate foods for
HEALTH EFFECTS a healthful diet—is
also a problem for
Food insecurity can affect health in a
some low-income
variety of ways. For example, an indi- families in the
vidual whose diet is lacking can expe- United States.

©2007 American Medical Association. All rights reserved. (Reprinted) JAMA, October 24/31, 2007—Vol 298, No. 16 1851

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