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Developments:
As yet another international AIDS conference prepares to kick off in Mexico City next week, the journal AIDS has published a special supplement that contains a think piece Tony Barnett of LSE and I wrote about the importance of hope to HIV infection. The abstract is here - please contact me for a more detailed summary. We argue that if people lack hope for the future, they will not engage in actions designed to protect that future. In the case of AIDS, this means that people will not wear condoms during sex and will have multiple sexual partners at the same time, thus dramatically increasing their risk of infection. In the poorest parts of the world, millions lack hope, and in some of the poorest parts of the world, AIDS is rife. We discuss the potential of cash transfers to trigger hope and thereby encourage people to behave in ways that will protect their health. The examples of microcredit and cash transfer programs like South Africa's pension scheme and child support grant, which have had strong impacts on recipients' health, suggest that such transfers can have broad positive effects, and may even help to cut HIV infections.
The World Economic Forum has just released 'Tackling Tuberculosis: The Business Response', the latest in a series of reports on corporate responsibility co-written by David Bloom, Lakshmi Reddy Bloom and myself. The study, which assesses the business impacts of TB and suggests ways firms can respond, was reviewed in The Hindu.
World Economics has just published a paper I wrote with David Bloom and others on the impact of HIV/AIDS on business. The main finding is that firms around the world are becoming more worried about the disease and experiencing greater impacts from it. Only in the very hardest hit countries, however (where adult prevalence is above 10%), do firms start taking serious action to tackle the threat. Firms in countries with generalised epidemics but where prevalence is below 10% do very little. Such inaction is likely to cost them in the long-run.
Most commentators on the Congressional resolution commemorating the Armenian genocide have adopted a US-centric view. Andrew Sullivan describes the move as “foolish in the extreme” because it will antagonize a key US ally. The University of San Francisco’s Stephen Zunes supports the decision because it is vital for the US to uphold its “longstanding principles.” But it’s not all about America – Turkey has some questions of its own to answer. See my thoughts on Turkey's complex relationship with its neighbours on the Global Dashboard blog.
Is the flu vaccine worth it? According to new research, probably not, at least for the elderly. Being vaccinated made elderly people no less likely to be admitted to hospital than those who were unvaccinated. Given the enormous effort the UK government goes to each year to make sure everyone over the age of 65 gets a jab, it might be an idea to establish whether the investment does any good.
I had this letter published in the FT this week, on the double standards surrounding Turkey's accession to the EU.
Farce in Darfur, as the Sudanese government appoints one of the International Criminal Court's two key war crimes suspects as head of a committee that will look into human rights violations in the province.
An interesting initiative in the Congo to train community volunteers to administer river blindness drugs. Why not use the same model to distribute antiretroviral drugs for AIDS? (Watch this space for a forthcoming article on the subject).
A paper I co-wrote last year on business and HIV/AIDS has been published in a special supplement to the latest issue of 'AIDS'. The paper follows on from the Durban workshop I attended in June 2006.
A programme to give out free insecticide-treated bed nets in Kenya has helped reduce child deaths from malaria by 44% in four years. Although the question of whether sleeping under nets prevents people developing immunity to malaria remains unanswered (I've asked several experts to no avail), free bed nets are beginning to look like a no-brainer in the fight against this devastating disease.
A timely article from the FT on the dangers the food miles fad poses to developing country food producers.
An effort to enlist the support of traditional healers in the battle against HIV/AIDS is beginning to bear fruit in South Africa. As well as encouraging their patients to access antiretroviral treatment and use condoms, sangomas are being trained not to re-use the razors with which they open wounds (I wonder how many HIV infections that practice has led to). When I visited Swaziland in 2004, I found healers reluctant to get involved with AIDS - given their respected status in society, however, their support is essential for limiting the spread of the virus.
Routledge has just published Solving the Riddle of Globalization and Development, which looks at the interactions between economic liberalization, human capital and development. David Bloom, David Steven and I wrote the book's chapters on Africa, Asia and Latin America. The Africa chapter, which traces the history of Africa's economic development, can be accessed here: Continental_Drift.doc
A good summary of the West's inept and hypocritical response to Darfur, explaining how the Sudanese government has outsmarted America, Britain and their allies at every turn.
Billionaire investor Warren Buffett is coming under pressure to sell his shares in PetroChina, whose parent company, the China National Petroleum Corp, has major interests in Sudanese oil. The Sudan Divestment Task Force, which has already persuaded Harvard University and other investors to withdraw their investments in PetroChina, believes the latter is helping fuel the Darfur genocide. As well as providing huge revenues to Sudan, most of which are spent on the military, PetroChina's stake in the country means its government can count on China's support in international negotiations to stop the slaughter.
Buffett doesn't think divesting will make any difference, as a subsidiary cannot control its parent, but Harvard found significant overlap between PetroChina and CNPC policies and there are rumours that the two are planning to integrate.
Google Earth provides hard visual evidence of the devastation in Darfur. It shows villages destroyed by the government-backed Janjaweed militia. The circles are burned-out homes.
Pharmaceutical giant GSK is about to make its new Globorix vaccine for meningitis A and C available at low cost in Africa. Although the company will not sell the vaccine anywhere else and is therefore unlikely to recoup its research costs, let alone make a profit, activists still complain.
It's not wealthy Westerners but poor Africans who should be really worried about avian flu. According to a recent study published in The Lancet, if a pandemic takes the same course as the disastrous Spanish flu of 1918-1920, 96% of deaths will occur in developing countries. Sub-Saharan Africa, home to 10% of the world's population, will see 29% of bird flu fatalities. Why? Because of poverty. Per capita income had a massive impact on who died of Spanish flu, and those who lack access to health care and are already weakened by disease and poor nutrition are no less likely to bear the brunt of an epidemic today.
In his final column on Asia for the FT today, Guy de Jonquieres makes an interesting point about the economic impact of political repression:"Most Asian governments dream of creating 'knowledge' societies capable of fundamental innovation. However, it is telling that almost all Asian-born Nobel scientific laureates have been honoured for work done in the west. Genuine innovations...challenge the established order. But even in countries where repressive regimes do not punish such behaviour, hierarchical attitudes and deference often breed intellectual conformism. Changing that will take more than big research budgets."
There is a petition here to persuade the UN and other human rights organisations to help stop two Darfurian women being stoned to death. The men they are supposed to have been with were acquitted. The women's trial was conducted in Arabic, a language neither understands. They were not allowed defence lawyers.
Sudan's government doesn't listen to the UN or to other governments, so there can't be much hope it would listen to a concerned public, but it's worth a try. The petition may at least help raise the profile of the genocide in Darfur.
This real-time death toll counter makes interesting viewing. Most killers are diseases of aging, such as heart disease and cancer, but infectious diseases also takes a heavy toll. Deaths from violence and war, on the other hand, are surprisingly low given the media coverage they receive.
A UNICEF programme, instigated during the country's 2005 food crisis, helps reduce child malnutrition in Niger. The programme is wide-ranging and its focus goes beyond food: as well as treatment to those who are malnourished, Vitamin A supplements, oral rehydration salts and deworming, it promotes handwashing, prevents diseases like measles and malaria which are more likely to be fatal if those infected are malnourished, and encourages women to breastfeed their babies (Niger, the world's poorest country, has its lowest rates of exclusive breastfeeding).
Signs of more concerted Western action on Darfur, as Bob Geldof persuades Tony Blair and a bunch of eminent writers to turn up the heat on Sudan and the UN.
While the UN Human Rights Council worries only about Israel's rights abuses, Sudan sentences two Darfurian women to death by stoning. The women had no defence lawyers and the trial was conducted in Arabic, which neither understands.
When the US State Department admits it's bad, you know it's bad. Worrying indications that the violence against civilians that has plagued Darfur is spreading into Chad and the Central African Republic. The Sudanese government, meanwhile, continues to frustrate the United Nations' timid efforts to send in peacekeepers, and the latter's new Human Rights Council passes resolutions only against Israel, and not against a country responsible for 200,000 deaths in the last three years.
A successful tree-growing campaign helps Niger slow the desertification process, with positive impacts on rainfall and, therefore, farming in this arid country. The campaign was started by farmers who realised their land was becoming ever less fertile. As well as halting soil erosion and increasing rainfall, the trees are a valuable source of both food and income, as branches and fruit are sold and the revenues invested in improved farming techniques.
Midday prayers on Fridays in Serrekunda, Gambia's main city, are an impressive sight. As the ezan is called from a nearby mosque, everybody stops what he is doing (women mysteriously disappear from view) and positions himself to face East. One side of the main street, Kairaba Avenue, is packed tightly with men standing in a line several hundred metres long. A petrol station forecourt is similarly crowded, with a dozen rows of worshippers huddled between the gas pumps. The opposite side of the street is empty, and the area's normally bustling commerce ceases while the prayers and prostrations proceed.
Nine of every ten Gambians are Muslims. Most are devout and regular worshippers, but they wear their religion lightly and relations with Christians, who make up most of the rest of the population, are healthy. As a young Christian hotel worker tells us, Muslim children are as keen on Christmas presents - usually in the form of money - as their Christian counterparts. Her co-religionists, meanwhile, take an enthusiastic part in Muslim festivals.
A last meal in Kartong, lunch with Pa Mane in his compound. First, a peeled jackfruit and some oranges. Then a bonga fish on a bed of rice, with a peppery sauce, eaten in the traditional way from a large enamel bowl, the dish shared between the three of us. Three rounds of strong, sweet green tea to finish. The whole thing takes about four hours.
Pa's wife occasionally comes to talk to him, holding their newborn baby on her hip. Children from the household and from neighbouring compounds hang around, staring at the "toubabs" (the universal description of and greeting to white people) before sloping off to play in the dust.
Pa tells us how he came to marry his wife. When he was 26, his mother told him to go out and find a bride. She needed help around the compound, and she thought it high time he settled down. Pa was busy working, however, making bamboo furniture across the border in Senegal, and two years later he hadn't even begun his search. His mother took matters into her own hands, and found him a young prospective bride in a village a few miles up the coast. Having failed to find someone of his own choosing, Pa was pleased to be relieved of the responsibility. If, on meeting for the first time, either he or the girl had not been keen, they could have declined his mother's proposal. Happily for the latter, who has handed many of her household chores to her daughter-in-law, they liked each other enough to tie the knot.
There are more arduous jobs than being a customs officer in Kartong. The border with Senegal is a bridgeless river, across which only pirogues pass. No vehicles enter the country here. Some boats used to land goods at the nearby beach, but now they dock further up the coast at Gunjur, as it means fewer corrupt police checkpoints to negotiate on the way to the capital, Banjul. The customs officer therefore has nothing to do every day. He sits all day in a small dark hut, resting his feet or his head on the metal desk in front of him. Sometimes he strolls along the road outside. Often he drinks green tea in his hut with passing villagers, shooting the breeze. Some days his office is closed, and he stays at home in Gunjur.
If he ever did have any levies to impose, he tells me, they would not be insignificant. The duty on kola nuts, for example, which are imported to Gambia from Guinea-Bissau, is 20%. On palm oil it is 15%. This still works out cheaper than palm oil produced in Gambia, but cross-border trade here is far from free.
Green tea, or attaya, is the beverage of choice in The Gambia. It is drunk in three rounds, each of which seems to take approximately 40 minutes to brew. Mohammed, a young roadside peanut seller who also makes a mean attaya, tells us that the lengthy brewing process allows time for drinkers and brewer to chat and share news. He puts a packet of Chinese "Gunpowder" green tea into a tiny enamel teapot, adds water and an enormous quantity of sugar, and boils it up over a charcoal burner. He then pours the resulting brew into a small glass, and from there into another, similar glass. Then back into the original glass. He does this at least thirty times (I lose count), unhurriedly, until there is a sufficiently thick foam resting on the tea. The first round is the strongest - the tea is dark and rich, much stronger than the green tea found in Chinese restaurants in the West. The second and third rounds are milder, though still powerful enough, and much sweeter.
After serving his guests, Mohammed takes a glass into his compound to give to his father. He returns and settles down on his stool to make the second round. Not a drink to ask for if you're in a hurry.
Just the one checkpoint on the road from Bakau to Kartong. The policeman waves at the taxi driver to stop, sees us in the back and after a mumbled, "good morning", waves us on. I congratulate our driver on not being asked for money. "He'll ask on the way back," he replies with a resigned smile. "What if you refuse to give him anything?" "Then he'll find a reason to fine me."
I haven't conducted a detailed survey, but from observation alone it seems a remarkably high proportion of young Gambian children have runny noses. Of course, in a country as open and friendly as Gambia you meet more kids than you do at home, but the difference in upper lip cleanliness is nevertheless striking. There are a number of possibly overlapping reasons for this, including poor nutrition increasing vulnerability to colds and making them harder to shake off; other health problems such as malaria depressing the immune system; crowded living conditions with close proximity to other children; frequent contact with animals; and exposure to indoor air pollution from burning wood, charcoal and animal dung for cooking. Or it could just be that noses are less frequently wiped.
According to Pa Mane, a local furniture maker, most young Gambians dream of meeting a white partner, who will either take them back to the comfort of his or her country or set them up in a compound or with a business in Gambia. Thousands of young people therefore flock to the tourist resorts to "find their luck". Not Pa though: he has worked in Senegal and Guinea-Bissau, but his goal is to stay in Kartong and become a farmer, growing and selling mangoes, cassava and groundnuts. His father left him a plot of land on the outskirts of the village, and he plans to clear it and make it ready for cultivation before the rainy season. Married with a young son, he wants another boy and a girl to complete his family. Unlike many here, he has no desire for more wives. "Too expensive," he says.
The Tesito Eco-lodge in the scrub outside Kartong was a project funded by the United Nations Development Programme to encourage environmentally-sensitive tourism in southwestern Gambia. After a promising start, the programme gradually disintegrated as the lodge's locally-employed managers either emigrated or found more rewarding jobs in the major tourist resorts. When the UN funding ran out, the project collapsed completely. The site became overgrown and the buildings began to crumble.
Today, a couple of villagers are trying heroically to resuscitate the lodge. Absent any more funds, they are looking to tourists to invest in the venture with them. All the rooms are empty when we visit, however, and none looks as if it has been occupied in the recent past.
Last year, thanks to a campaign to provide the entire village with insecticide-treated bed nets, nobody in Kartong died of malaria. There is no room for complacency, however. Musa, a 17-year-old student, caught the disease last summer and was seriously ill. He knows he should sleep under a net but in summer, he says with a wry laugh, "it's too hot, so we sleep outside."
Front page news in an edition of Gambia's Daily Observer newspaper last week announced a message of best wishes from the President of Benin to President Jammeh, wishing him and all Gambians good luck in the new year and expressing hope that the good relations between the two countries will continue.
How did they end up here? (An occasional series)
The Kartong highway stops abruptly 3km after the last village in Gambia. Where the tarmac ends, two red earth tracks lead off to right and left. The rightward track passes between desolate salt pans to a fishing beach, where Gambian and Senegalese fishermen weigh and sell their catch. At the end of the leftward path lies the Hallahin river, which doubles as the Senegalese border. The jungly fringe of Senegal's troubled Casamance region lies a hundred metres across the slow-moving stream. Oarsmen in slender pirogues ferry occasional passengers between the two countries carrying bags of rice or bicycles. An utterly peaceful spot, the only sounds are the plop of oars and kingfishers diving into the water.
On this remote shore, Franco, a small, intense, middle-aged Italian, has a tiny restaurant with a terrace overlooking the river. He serves up oven-cooked pizzas to a sparse clientele of expats from the capital and bemused, possibly lost tourists. His English is stilted and my Italian nonexistent, and I don't ask how an Italian pizza chef ended up here, at the end of Gambia, far from the nearest village and many miles from the nearest tourist resort. His business seems to be surviving, however, and three of the tables are occupied when I visit. Perhaps these things are best unasked; the mystery, like the tranquil river, left undisturbed.
At the sacred crocodile pool in Kartong, two female elders from the village sit in the dust rolling tasbih beads between their fingers and intoning Arabic prayers. Pilgrims come from as far away as Mali and Guinea-Bissau to ask the women for blessings. Promotion at work, resolution of arguments and, most of all, fertility are among the most common requests. Candles, kola nuts and cash are given in return.
On the day I visit, the brother of an MP from Bakau near the capital is here, sitting cross-legged by the shady pool. The elders, clad in headscarves and with their legs stretched out in front of them, sit some yards behind him, chanting their dirges. Before the recent local elections, the MP himself had come to Kartonko to pray for assistance during the campaign. The ballot won, he has sent his brother to offer thanks.
After the prayers finish, one of the women climbs down the slope to the pool and scoops some water into a tin (the crocodiles, which are not visible today, are harmless to humans). The MP's brother takes the water to wash in a nearby hut. The pool has never dried up, even in the keenest drought, and it is said that if you photograph one of the crocs, it will not appear on the developed print.
Gambia's President Yahya Jammeh claims to have found a cure for AIDS. "I can treat asthma and HIV/AIDS," he told foreign diplomats in January. "Within three days the person should be tested again and I can tell you that he/she will be negative." Jammeh's cure uses herbal medicines whose identity must for now be kept secret. The international HIV/AIDS community is up in arms, seeing in Jammeh's actions alarming parallels with the South African government's "beetroot and garlic" stance on AIDS treatment, which may have led to millions of deaths.
At a beach near the village of Kartong in south-western Gambia, you can buy a bonga fish direct from the fishermen for 1 dalasi (about 2p). By the time it reaches the village market, 3km away, its price has doubled.
A Gambian child selling oranges in the city of Serrekunda understood how the economics of adding value works. He was selling peeled oranges for 2.5 dalasis each from his barrow on a street corner. I wanted an unpeeled orange, and expressed surprise when he said it would also cost 2.5 dalasis. Neither of us spoke each other's language, but when I mimed the gesture of peeling the orange, and implied that the work involved should increase the product's price relative to the unpeeled fruit, he twigged immediately, and explained to a bemused-looking friend the reasoning behind my argument. He must have been about 7 years old. Despite his precocious intelligence, however (or perhaps because of it), he still wouldn't drop his price for the unpeeled orange.
Arriving in Banjul Airport in The Gambia, two things are immediately striking. The first is a large advertising hoarding on the side of the airport building proclaiming Gambia's role as host of the 2006 African Union summit. President Jammeh, a large, portly figure, sweating even in his propaganda photos, smiles down at new arrivals. The second is the empty four-lane highway covering the half-mile stretch from terminal to airport gate. The latter is perhaps the best road in the country.
The Gambia is one of the world's poorest countries, ranking 155th of 177 countries in the United Nations 2005 Human Developoment Index. Many families cannot afford to send their children to school, malaria claims thousands of lives each year, and unemployment is widespread.
Despite these problems, the President invested millions of dollars in the AU summit, including over $5m for new villas for visiting heads of state. He also flew in his friends, Presidents Chavez of Venezuela and Ahmadinejad of Iran. A supporter of nefarious former West African leaders Sani Abacha of Nigeria and Charles Taylor of Liberia, Jammeh is slowly sucking in power and wealth like a sponge. Political opponents are silenced, the press muzzled. Elections are won by comfortable margins, even as the price of rice and other foods rises beyond many Gambians' means.
South Africa's Mail & Guardian newspaper has published my latest HIV/AIDS article in its World AIDS Day special supplement today.
The article argues that the "broken windows" approach to crime prevention can also be applied to the fight against HIV/AIDS. Small steps towards creating a culture of responsibility, such as clamping down on speeding, drink-driving, littering etc, can help promote the behaviour change needed to slow HIV transmission. As Malcolm Gladwell argued in The Tipping Point, an epidemic - be it of crime or disease - can be reversed “by tinkering with the smallest details of the immediate environment”.
My article on new approaches to HIV prevention appeared in South Africa's Business Day newspaper last week. The article argues that, despite all the talk of new technologies such as vaccines and microbicides, behaviour change remains the key to prevention. It then lays out some new approaches, including social network analysis, ideas for better safe sex, and incentives for business involvement.
Signs of a positive shift in South Africa's HIV/AIDS policy, as loony Health Minister Manto Tshabalala-Msimang is marginalised in favour of Deputy President Phumzile Mlambo-Ngcuka, who seems to accept that the disease is caused by a virus and not a failure to eat beetroot.
The UN's recently-expelled Special Representative in Sudan, Jan Pronk, last week told the Security Council that the Sudanese government was still looking towards a "military solution" for Darfur. In other words, keep your peacemakers out until we've finished the genocide. The international community, meanwhile, looks on powerless as the damage spreads to Chad and the Central African Republic.
British American Tobacco (BAT) is fighting Uganda's successful malaria control campaign because the DDT it uses may damage the company's tobacco crops. Sometimes the business-bashers are right.
A 2004 survey by the SA Advertising Research Foundation found that, as a result of HIV/AIDS, South Africans spend more time at funerals than shopping, having barbecues or visiting the hairdresser.
Bad news on tuberculosis, as a "virtually untreatable" form of multi-drug resistant TB has emerged as a threat to health in both developed and developing regions. People infected with HIV are most at risk.
A fascinating article by Malcolm Gladwell in the New Yorker relates how the recent economic booms experienced by Ireland and East Asia were driven by a "demographic dividend".
As my associate David Bloom explains in the article, demographic dividends occur when the number of people of working-age in a country rises sharply - because of baby booms or reductions in fertility - compared to the dependent population of children and the elderly. This means that resources that have previously been spent on child care, health care and pensions are freed up for productive economic activity.
In contrast to East Asia, Africa still has a high proportion of dependents to workers. As Gladwell observes, this would "frustrate and complicate economic development anywhere". Africa needs to get its birth rate down if it is to achieve similarly favourable demographic conditions, but it also needs a job climate that can absorb a swollen workforce.
A study I conducted last year with the Swiss Tropical Institute sheds further light on the low HIV infection rates in West Africa.
1,020 young people from the Upper East Region of Ghana took part in the study, which surveyed their attitudes to sex and HIV/AIDS and asked them about their sexual behaviour. Awareness of HIV/AIDS and of its main transmission channels was high, but 40% of respondents believed the virus could be contracted through kissing. Abstinence is seen as the key prevention method, perhaps reflecting the strength of the Church in Ghana. Condoms are less trusted, with a significant minority having negative perceptions of their safety.
Knowledge of HIV transmission and prevention is weaker among women in the survey than men. Ghanaian women aged 15-24 have much higher HIV infection rates than men of similar age, so it would appear important to ensure that AIDS education campaigns reach people of both sexes (please e-mail me for a full report of the survey).
Last week saw the release of 'Business and Malaria: A Neglected Threat?' , a report co-written by David Bloom, Lakshmi Reddy Bloom and myself for the World Economic Forum. The report is the most comprehensive ever produced on the effect of malaria on business.
Based on data from the Forum's annual Executive Opinion Survey of 10,000 business leaders worldwide, the main findings are:
- 39% of respondents in Sub-Saharan Africa report that malaria is currently having serious impacts on their business
- In countries where malaria is present, 40% of firms expect the disease to affect their business within the next five years
- Firms in countries where malaria is epidemic are more worried than those where the disease is endemic. This could reflect the greater uncertainty of epidemics, which makes it harder for business to prepare for them, or the fact that epidemic malaria takes a greater toll on working-age adults than endemic malaria
In the ongoing battle against HIV/AIDS, probably more significant than the big Toronto AIDS conference next week is the discovery that male circumcision reduces the risk of HIV transmission from women to men by 60%.
The effect is so large that it could explain the mysterious gap between infection rates in West Africa (where many men are circumcised and HIV prevalence is relatively low) and Southern and East Africa (where few are circumcised and infection rates are soaring). According to Richard Feachem of the Global Fund to Fight AIDS, Tuberculosis and Malaria, "Other things being equal, in a circumcised population you have a low and slowly developing epidemic and in an uncircumcised population you have a high and fast developing epidemic."
The Daily Telegraph has picked up on my MMR article. Interestingly, a Kent University sociology professor reports that African parents voiced concerns over the safety of the vaccine to him on a recent trip there. The Pan-American Health Organization, meanwhile, warned South American travellers to the World Cup to get vaccinated, as reduced MMR uptake in Germany has led to measles outbreaks there.
In late June I attended on behalf of the World Economic Forum a think tank on Business & AIDS, held in Durban, South Africa. The meeting was hosted by UCLA's David Geffen School of Medicine. Its 60 participants from business, government, academia, NGOs and the media examined the epidemiology of HIV/AIDS among workers in South Africa, the impact on the workforce, and the efficacy of workplace HIV/AIDS prevention and treatment programs.
Among the most interesting challenges facing those advocating for greater business involvement in the struggle against AIDS is the issue of small and medium enterprises. SMEs in southern Africa have hitherto displayed little interest in implementing programs - most do not see the virus as a serious problem and those that do lack the resources to deal with it. A few promising solutions were mooted at the seminar, including large firms encouraging and helping their SME suppliers to develop programs, business associations playing a more prominent role, and clusters of small firms working together to share knowledge and tools. Perhaps the first question that should be asked, however, is whether small firms should act on HIV/AIDS at all.
South Africa's Business Day and Ghana's Accra Daily Mail have published my "Bad science, bad health" article, on how health scares in the West can have devastating consequences for people in the developing world.
Focusing on the MMR vaccine controversy, the article argues that if parents in developing countries follow the lead of their Western counterparts by refraining from vaccinating their children, the health impacts could be fatal.
A thoughtful article on the unintended consequences of foreign aid, from an unlikely source - the left-leaning New Statesman.
I spent last Saturday in Belfast, facilitating part of the National Pensions Debate for the UK Department of Work and Pensions. Over 1,000 people gave their views on the future of pensions in six cities across the UK. Participants discussed the National Pension Commission's proposals to raise the retirement age, spend a higher proportion of tax revenues on pensions, and encourage employers and employees to contribute to a national pensions savings scheme. Interestingly, participants on my table would prefer to pay more taxes than work more years: it seems the government has yet to convince people that longer life expectancy makes a rise in the retirement age not just economically sane but also, relative to shorter-lived previous generations, fair.
3 quotes:
“[It is] alarmingly clear that the corruptive system in Zaire with all its wicked and ugly manifestations, its mismanagement and fraud, will destroy all endeavours of institutions, of friendly governments, and of the commercial banks towards recovery and rehabilitation of Zaire's economy. Sure, there will be new promises by Mobutu, by members of his government, rescheduling, and rescheduling again of a growing external public debt, but no (repeat: no) prospect for Zaire's creditors to get their money back in any foreseeable future.”
(Report by Erwin Blumenthal to the IMF, 1982)
"If you steal, do not steal too much at a time...Steal cleverly, little by little."
(President Mobutu Sese Seko of Zaire in an address to party regulars, 1991)
“In Kenya I met President Kibaki. We had a full and frank discussion, as they say, about the persistence of corruption. I made no secret of our concern. During the same visit, I also announced that we will be putting £55 million into improving education.”
(Hilary Benn, UK Minister for International Development, Speech to the Royal African Society, 2006)
From the London Sunday Times, on the Ugandan election campaign: "Apart from a shooting incident on Wednesday when a reserve soldier panicked when challenged by a crowd, opening fire and killing several people, campaigning has been largely peaceful." Note that "apart from". And would an election campaign in London that involved multiple deaths be described as "peaceful"? The West clearly, and reasonably, expects less of Africa than of its own democracies. But a reader might also reasonably conclude that in the eyes of some Westerners Africans' lives are less valuable.
The latest of our reports for the World Economic Forum on the impacts of HIV/AIDS on business (co-written by David and Lakshmi Bloom, David Steven and myself) was published yesterday .
'Business and HIV/AIDS: A Healthier Partnership?', which also reviews case studies of action on HIV/AIDS by major multinational firms such as Nike and GM, finds that businesses are becoming more concerned about the virus and that those based in the hardest-hit countries have begun to develop policies to tackle it. Elsewhere, however, even where adult HIV prevalence is increasing sharply, few firms have responded to the disease and those policies that do exist are often threadbare.
Yesterday's London Times carries a good summary of the report, and the BBC presents some of our key recommendations for businesses.
The King of Lesotho is to test for HIV. A potentially stigma-busting move, that will hopefully set an example to other African leaders.
Since bird flu was discovered in Turkey, the price of chicken has almost halved. Another example of health affecting economies.
The Economist has picked up on a paper I co-wrote with David Bloom and David Canning of Harvard University on the 'Value of Vaccination'. The paper, published in this quarter's World Economics, shows how vaccinated children score more highly than those who are unvaccinated in language and IQ tests. As well as the obvious health advantages, therefore, immunisation has large economic benefits. The $13 billion campaign by the Global Alliance for Vaccines and Immunisation (GAVI) to vaccinate children in the world's poorest countries by 2020 will ultimately generate a return of 18%, making immunisation at least as beneficial an investment as more fashionable development goals such as education.
Reuters article on 'Pushing Back The Tide', a report I co-wrote with David and Lakshmi Bloom on the business response to HIV/AIDS in Asia. The report, which presents data from the World Economic Forum's annual Executive Opinion Survey, finds that Asian businesses are concerned about AIDS and have begun to develop responses to it. They lack clear information on how the virus will affect them, however, so their responses may prove not to be wholly effective.
In particular, few firms' policies address the stigma surrounding HIV infection - an oversight which is likely to seriously undermine efforts to combat the disease.
An impressive pair of maps showing the amazing progress of the worldwide polio eradication campaign. Although the virus remains endemic in a handful of countries, including populous India and Nigeria, it has been wiped out in most of the world.
A promising initiative to engage traditional healers in HIV/AIDS treatment and care in South Africa. As noted last year, traditional healers have hitherto had little involvement with HIV, but given patients often have closer relationships with them than with allopathic doctors, enlisting their support may be vital for expanding treatment.
According to Britain's Sun newspaper, when the UK government wrote off £35 million of Tanzania's debt in 2004, President Mkapa went out and spent £30 million (other sources say £15 million, but hey) on a new private jet. Still think debt relief is a panacea for Africa?
Congratulations to the Make Poverty History campaign, which has apparently been contracting Chinese sweatshops to make its wristbands (worn by Tony Blair and Coldplay's Chris Martin, among other luminaries). Given that sweatshops have been a key step on the development ladder for many emerging nations, it's good to see the campaigners are practicing what they preach.
A rare good news story from Africa, as Reuters claims the continent "has never looked more promising as a business destination." As I wrote from Ghana last year, things are indeed looking up in some parts of the region, though South Africa's long-term future looks less assured.
Depressing news from South Africa as the government persists with its ludicrous "poverty causes AIDS" campaign. This week, Health Minister Manto Tshabalala-Msimang claims that raw garlic and lemon zest are as effective against the disease as antiretroviral drugs. Not only that, they also give you "a beautiful face and skin". At least you'll look pretty on your deathbed.
A South African friend of mine was shot three times in the back at the Caltex garage in Mtubatuba last Friday. The assailants, who in November 2003 had hijacked him and stolen his car, recognised him as a witness against them and started shooting. Fortunately, thanks to South African hospitals' world-renowned expertise in treating gunshot wounds, he survived and is recovering in intensive care.
Safe Sex Sucks: The South African Mail & Guardian this week published my article on how oral sex can assist in HIV prevention. "Oral sex", the article concludes, "makes sex both more fun and less risky. As a means of reducing HIV infections in Africa, it shouldn’t be such a hard idea for policy-makers to swallow."
How rich are you? A humbling site for most people living in the wealthy West.
This week in Davos sees the publication of Business and HIV/AIDS: Commitment and Action?, a report commissioned by the World Economic Forum that I co-wrote with David Bloom, Lakshmi Reddy Bloom and David Steven. The report assesses the global business response to HIV/AIDS, drawing on the Forum's annual Executive Opinion Survey of business leaders. It finds that although concern among executives does not appear to be rising, firms' response to AIDS, particularly in hard-hit Sub-Saharan Africa, is becoming much more concerted.
When I came to Turkey two years ago, nobody I spoke to wanted the IMF's help in rescuing the country's floundering economy. Some feared a repeat of what happened in Argentina, others saw it as a slight on Turkey's ability to look after itself. Today, however, with inflation down from 70% to 9% and the economy growing fast, those same doubters are grateful for the IMF programme. "Argentina was an IMF failure," said one, "but they'll be able to hold Turkey up as a success."
When a ship arrives in the port of Iskenderun in southern Turkey, its agents pay a $50 bribe to customs officials to process their docking papers quickly. If you don't pay the bribe, your ship can be stuck in the port for days.
According to a young shipping agent I talked to, if anyone reported the practice to the police their future in the tight-knit world of the shipping industry would be bleak. Customs officials receive pitifully low salaries so rich agents don't mind stumping up the $50 "fee".
"Wouldn't they still want bribes if they had higher salaries?", I asked. "They would," he replied, "but agents would be much less sympathetic."
World Economics has just published "Governance Matters", an article on the role of governance in Asian economic development, co-authored with David Bloom and David Steven. See also "Why good government is necessary" - an op-ed which appeared in the Taipei Times, and various other papers.
Sir, A serious problem with disaster relief is getting aid to people on the ground without it being skimmed off by corrupt politicians or well-paid bureaucrats. With over £2bn already pledged by rich nations to the countries hit by the tsunamis, the risk of waste is particularly high. To circumvent this, why not give, say, £500 to each person in the affected areas, and allow human ingenuity to do the rest? It would make for a much more effective response (Letter published in today's Financial Times. A similar letter made it into the Economist).
Everyone's worried about cholera spreading among survivors of the Asian earthquake, but what exactly is it? As this excellent summary shows, cholera is basically a severe diarrhoea-like illness that's easy to catch but also, if attended to quickly, easy to treat.
An African view of the Nevirapine saga, suggesting the fuss over the drug is likely to do a lot more harm than good to Africans infected with HIV.
With James Wolfensohn stepping down, a new World Bank President will be appointed soon. worldbankpresident.org has all the latest gossip.
Although natural disasters are an inevitable fact of life, the havoc they wreak can be prevented. Had the Boxing Day earthquake hit a wealthy part of the world, the death toll would have been far lower and the destruction of survivors’ lives less widespread. In affluent Japan and Taiwan, for example, massive earthquakes in the 1990s killed a total of just 9,000 people (even the famous San Francisco quake of 1906 caused only 3,000 deaths). The recent tremors in poorer Iran and India, by contrast, killed over 80,000.
The reason the Asian earthquake has produced such carnage is because the countries it hit are mired in poverty. Prosperous countries are better able to cope with natural disasters. They have more efficient communications systems to provide early warnings. Their people live in more robust dwellings that are less likely to be flattened or washed away. Rescue and medical services are better equipped and more effective. Drainage and water supply systems are more resilient, thus reducing the need to rely on contaminated water and lessening the risk of disease. Stronger transport infrastructure, meanwhile, makes it easier to get help to victims, while governments with money in the coffers do not have to wait days or weeks for assistance to arrive from abroad.
Sending aid in response to disasters is essential and admirable, but such efforts provide short-term fixes rather than long-term solutions. Unless the deeper problems of poverty are addressed, events like those in the Indian Ocean will continue to cause enormous but preventable damage.
Carjacking training, the Africa Centre for Health and Population Studies, Kwa-Zulu Natal: - Keep car doors locked and windows shut at all times
- Watch out for groups of two or three men at road junctions
- Avoid having to stop at red lights
- Stop as briefly as possible at other junctions
- If you do have to stop, leave enough space between you and the car in front to enable you to drive past it in an emergency
- At night, if you've messed up the traffic lights and have to stop when there is a group of young men loitering, run the red light
- If you break down in a rural area, leave the car behind and hide in the bush until help arrives - keep a mobile phone with you at all times
- A significant proportion of carjackings results in the car owner being shot
- In the event of being carjacked, do not look the carjacker in the eye
- If the carjacker asks you to get out and you have to release your seatbelt, tell him what you're doing so he doesn't think you're reaching for a gun
- If he gets in and asks you to move into the passenger seat, try to escape through the passenger door
- If he gets in and asks you to drive, drive off at high speed and, before he can fasten his seatbelt, crash the car into a tree or building and hope your seatbelt saves you
Dr Narendra Hadpawat arrived in New York from India in 1974 with $8 - the maximum sum that could be taken out of India in those days. He stayed with one Indian friend who had moved to the US shortly before, and borrowed $300 off another so he could buy food and search for a job. Another Indian immigrant fixed him up with an interview in a hospital in Buffalo. Hadpawat got the job, brought his wife and young child over, and worked his way up the medical ladder. He now has his own practice and lives in a large house on Long Island.
Today, Dr Hadpawat is returning the favour. As well as volunteering for the Rajasthan Association of North America, which runs educational projects and cultural programs to promote development back in India, he also helps new immigrants find jobs, homes and, occasionally, wives. "Earlier immigrants helped us," he says, "so it's our duty to help the new generation."
Ryszard Kapuscinski on development: "Development is a treacherous river, as everyone who plunges into its currents knows...the Shah is making purchases costing billions, and ships full of merchandise are steaming toward Iran from all the continents. But when they reach the Gulf, it turns out that the small obsolete ports are unable to handle such a mass of cargo (the Shah hadn't realized this). Several hundred ships line up at sea and stay there for up to six months, for which delay Iran pays the shipping companies a billion dollars annually. Somehow the ships are gradually unloaded, but then it turns out that there are no warehouses (the Shah hadn't realized). In the open air, in the desert, in nightmarish tropical heat, lie millions of tons of all sorts of cargo. Half of it, consisting of perishable foodstuffs and chemicals, ends up being thrown away. The remaining cargo now has to be transported into the depths of the country, and at this moment it turns out that there is no transport (the Shah hadn't realized). Two thousand tractor-trailers are thus ordered from Europe, but then it turns out there are no drivers (the Shah hadn't realized). After much consultation, an airliner flies off to bring South Korean truckers from Seoul. Now the tractor-trailers start rolling and begin to transport the cargo, but once the truckdrivers pick up a few words of Farsi, they discover they're making only half as much as native truckers. Outraged, they abandon their rigs and return to Korea. The trucks, unused to this day, still sit, covered with sand, along the Bander Abbas - Teheran highway..." (Ryszard Kapuscinski, Shah of Shahs, 1982).
Nigeria, according to the International Herald Tribune, borrowed $5 billion from various development banks in the 1970s and '80s. Because of interest charges, it has so far paid back $16 billion and still owes $32 billion.
Hlabisa, South Africa: The reed dance, where 15,000 virgins dance semi-naked before the Zulu King, was held last weekend. The story goes that once upon a time, a group of Zulu maidens were bathing in the river. They were attacked by a man intent on raping them. The maidens beat him away with reeds, and went to tell the King that they had been attacked but preserved their honour. Their heroics are now celebrated every year.
This year's dance incorporated HIV prevention messages which emphasised that virginity is something to be proud of. When I asked a friend of mine who attended the dance how they knew the girls were virgins (most girls in the area are sexually experienced by the age of 17), he replied that he had accidentally wandered into the "virgin testing area", thinking it was a beer tent. After he made a hasty exit (having realised he was the only male in there), my friend was told the girls were being tested manually by elderly ladies.
Price list for the services provided by a traditional healer (or 'sangoma') in a village near Piggs Peak in Swaziland:
- Curing sexually transmitted diseases: £42
- Curing epilepsy: £68
- Curing madness: £85
- Procuring promotion at work: £127
- Procuring business success: £152
- Telling your fortune: £4.20 Swaziland is one of the poorest countries in the world - the average annual income is £663. It also has the highest HIV prevalence rates in the world, though the sangoma admits to having no cure for AIDS and no interest in telling people how not to contract it: "Our job is to heal," she tells me, "not to prevent". When she herself falls ill, she visits a medical doctor. A sangoma, she explains, cannot heal herself.
The Asian Development Bank has just published 'Asia's Economies and the Challenge of AIDS', a monograph I co-wrote with David Bloom and David Steven. The book makes three main points. First, HIV/AIDS is likely to spread at a modest rate in Asia compared to Sub-Saharan Africa. Second, even at moderate overall prevalence levels, the epidemic will have a negative impact on Asia's economic development, but it will do so primarily through its effect on vulnerable groups such as women, the poor, the less educated, and people working in particular occupations such as sex work and truck driving. Third, spending on HIV prevention and AIDS care is powerfully justified by the high economic returns that can be expected to flow from such spending. The book can be viewed online or ordered here.
Since the beginning of the conflict in neighbouring Cote d'Ivoire, HIV infection rates in northern Ghana have shot up. Truck drivers from Mali and Niger used to offload their goods in Cote d'Ivoire's ports. Now they use Ghana's instead, and the sex trade around the Burkina Faso border has flourished. HIV rates in Ghana are low relative to the rest of the region, with around 3% of adults infected (in Cote d'Ivoire over 10% are infected). The Ghanaian government wants to keep it that way, and has intensified its impressive education campaigns aimed at young women in high-risk border areas.
Malaria is Ghana's biggest killer. A study by the Navrongo Health Research Centre found that sleeping under bed nets soaked every six months in insecticides reduces the number of deaths in children below the age of five by 17%. Although the nets aren't cheap (they cost £7-10), even those who can't afford them may benefit, as the study also found that the more insecticide-treated bed nets a community has, the fewer mosquitoes it attracts. The Ghanaian government has incorporated bed net provision into its health care strategy, and plans to provide nets at reduced rates to mothers of young children.
Female circumcision, although illegal, is common in northern Ghana. In the Kassena-Nankana District, near the Burkina Faso border, two thirds of young women are circumcised, usually around the age of 15. The operation involves cutting off a woman's clitoris, nearly always without an anaesthetic, and can cause fistula and problems during labour. In a survey by the Navrongo Health Research Centre, women described the practice as a rite of passage. Only circumcised women, they said, are fit to perform their mothers' funeral rites. By controlling their sexual desires, moreover, circumcision makes women more faithful to their husbands.
Becky, a 20-year old waitress in a bustling streetside bar in downtown Accra, earns the equivalent of £1.20 a day , including tips, working from 7am to 5pm five days a week and from 7am to 4am (a 21-hour shift) on Fridays. 30p of this goes on transport to and from work. A further 40p goes on food. She lives with her aunt so she doesn't have to pay rent (she cleans the house and does a lot of the cooking instead). Every other Sunday she treats herself to a visit to the hairdresser, which costs £2. That leaves her with about £1.60 each week.
After leaving school a year ago, Becky couldn't afford to go to university, but now, after four months working, she has managed to save enough to attend three months of a computer course (cost: £15), starting in September. She's hoping to save a further £30 so she can attend the remaining two modules in the spring. Lessons are in the evening after work and they should make it easier to find a better job. Among Becky's other plans in the next year are to rent a room in town with her cousin and to buy a mobile phone (cost: £100). Even on a salary of £1.20 a day, she thinks her goals are achievable. So far, her calculations have been right.
A wander round the poor district of Jamestown is an intense experience. The stench of open sewers and acrid-smelling food, noise blaring from a thousand radios, children soaping themselves in front of their shacks, and grown-ups shouting to each other across the street and scolding errant offspring make for a cacophonous assault on the senses.
Even here, though, there are signs of development. The streets between the shacks are paved, hefty fish and plump fruit and vegetables are on sale in the market, foreign exchange bureaus serve those who have received remittances from relatives abroad, and everybody seems to have something to sell. There is a surprising number, too, of men and women in suits, a few foreign-made cars roll slowly through the streets, and telephone exchanges abound. Old, chaotic Jamestown, it seems, like the rest of Accra, is on the way up.
Accra is full of entrepreneurs. At every traffic jam - the city is one big traffic jam - you are besieged by hawkers of all ages, selling anything from chewing gum to mattresses. The contrast with South Africa, where despite high unemployment few go into business on their own, is stark.
Collection of the levies for Ghana's ambitious National Health Insurance Scheme began today. The scheme aims to provide affordable basic health care to all Ghanaians, and free care to the poorest. It wil be funded by a 2.5% value added tax on certain items, and a monthly subscription of 6,000 cedis (around 35p) for those who can afford to pay. Some of the savings from Ghana's recently announced debt relief will also be used. President John Kufuor hopes the NHIS will replace the country's "cash and carry" system, which leads to such perversities as healthy people being detained in hospitals because they can't pay their fees. A detailed description of the scheme is available on allAfrica.com.
Late last night, my taxi home was stopped by three soldiers at a checkpoint. They checked the car over and examined the driver's license. Both car and license were fine, but the soldiers demanded a 5,000-cedi bribe to let us go. 5,000 cedis is about 30p - 20% of the fare. The driver paid up, explaining, "if you don't pay, they spend more time on you."
An Accra mother was caught trying to smuggle her new-born baby out of hospital in a shopping bag last week. She couldn't afford the fees. This is not uncommon - beds in the city's maternity wards are often occupied by perfectly healthy women, detained while their families scrape together the money to get them out.
Conversation with an Accra taxi driver: "What do you think of President Kufuor?" "Too much corruption, man." "Hasn't there always been corruption?" "There's more now. Rawlings was a military man. Strong. He didn't allow corruption." Jerry Rawlings has had his two terms as President - the maximum allowed - but still wields influence in the opposition NDC party. Fortunately there's an election coming up. "We're going to sack Kufuor, and him and his party are gonna be out of power til me I die."
Accra, Ghana: Ghana's debt has just been reduced from $1.6 billion dollars to $300 million. According to a government spokesman, this will give the country $250 million extra each year to spend on [much-needed] infrastructure improvements. Ghana is in most international agencies' good books. It receives more British aid relative to its population size than any other country. International NGOs, keen to pick winners, are all over the place like a rash.
Compared to those in India, South African villages, towns and cities are bleak and lifeless places. The pavements are mostly empty, commerce is confined to shopping malls and those who do brave the streets are normally hurrying to get off them. Crime is one reason for this, but the absence of a sense of community among black South Africans is perhaps more to blame. The effects of apartheid, which deliberately tore apart black families and communities, endure in their low rates of marriage, high rates of migration and lack of concern for fellow community members. Men therefore prefer to risk transmitting HIV than protect their partners by wearing condoms. Workers in an organisation I visited last week prefer that nobody receive any medical benefits than that some get antiretroviral treatment for AIDS. And taxi drivers prefer to shoot rivals who steal rides from them than come up with a sensible queuing system.
Under apartheid, the struggle against a repressive regime helped unite black communities. Now, however, there is nothing to fight for. A few black South Africans have grown rich and moved into white suburbs, many others languish in long-term unemployment. The depression and apathy of individuals, meanwhile, has spread to society as a whole.
Hlabisa hospital, which looks after a district where over 20% of adults are infected with HIV, has been refused permission to begin its antiretroviral drug program. The South African Government has pledged to provide ARVs to those who need them, but hospitals must be accredited first. One of the criteria for accreditation is the hiring of a dietician. Patients can begin and continue antiretroviral programs perfectly well without a dietician's assistance, and trained dieticians are extremely scarce (six hospitals in this region currently share one). The Government, however, whose Health Minister recently recommended that those infected with HIV eat spinach, beetroot, garlic and olive oil to boost their immune systems, is sticking to its lethal "poverty causes AIDS" agenda and making AIDS patients wait for their treatment.
The Government of Zambia spends the equivalent of $50 per year on each Zambian's health. Given the country's high rates of HIV infection, an antiretroviral drug program will require a quadrupling in health spending. This will save money in terms of hospital costs for sick patients and working hours lost to AIDS, but in a country where two thirds of the population lives on less than $1 a day and half are undernourished, diverting funds to ARV programs will inevitably mean other valuable investments being curtailed.
After years of being raped by her father, a local teenage girl found out she was pregnant. At the antenatal clinic, she tested positive for HIV. The girl told her mother and the police and then ran away from home. The father fled, but sent a message threatening to kill his wife and daughter. All three are now on the run. Last month the girl, who is still in touch with local social workers, gave birth to dead twins.
Malcolm Gladwell, in The Tipping Point, writes of the role of "Connectors" in spreading social epidemics. Connectors are community members whose vast range of contacts puts them in a strong position to spark new trends or influence behavioural change. They are what African populations ravaged by AIDS need. The stigma surrounding AIDS means most of its victims die rather than admit to being infected. That stigma can be broken if influential individuals admit their infection and tell others it is nothing to be ashamed of. It's not an easy decision to take, and one man who bit the bullet in Hlabisa found that nobody believed his admission because he continued to look healthy. Those Connectors who do spread the message, however, could be the most effective weapons yet in the battle against the virus.
The local STD clinic ran out of drugs on Monday. It's now Friday and there is still no sign of new supplies. This is not an unusual occurrence. Drugs often arrive late from the central distributor in far-off Pietermaritzburg, so clinics order more than they need to tide them over until the next batch comes. The central distributor is aware of this practice, however, so he sends less than what the clinics ask for. The clinics, in turn, factor the distributor's cunning into their orders, which they inflate still further. This week, it seems, the distributor emerged victorious, with patients, of course, the unwitting victims.
An 8 year old boy was run over and killed this morning on the road out of Mtubatuba. His brother, who was kneeling by the body, said his mother is bedridden with AIDS. He buried his father, who died of the disease, on Sunday.
Some important happenings by which the older citizens of Hlabisa, who are not familiar with the calendar, date key events in their lives:
- The year the sugar mill was built (1916)
- The year the floods washed away the railway bridge (1925)
- The year of the plague of locusts (1932)
- The year Chief Mtubatuba died (1955)
- The year the N2 was tarred (1962)
- The year people were moved [from Richards Bay to Ntambanana] (1976)
- The year Steve Biko died (1977)
- The year of the drought (1982)
- The year the Umfolozi bridge collapsed (1984)
- The year President Mandela was released (1990)
- The year of the first democratic elections (1994)
A German epidemiologist arrived here for a 2-year stint last week. He was sent by the German governmental body CIM (Centre for International Migration). CIM was set up in the 1960s to help people from the developing world who had completed their studies in Germa | |
