We are not your pilot program
My grandmother walked three hours to a clinic in rural Senegal to get my mother vaccinated in 1971. The clinic was a pilot program funded by USAID. It ran for two years. When the funding cycle ended, the clinic closed. My mother got her first dose. She never got her second.
That pattern — arrive with a program, collect the data, publish the paper, leave — has been running in Africa for sixty years. The public health camp calls it the last mile problem.
We call it the first mile problem. The infrastructure was never built because nobody planned to stay.
The malaria vaccine took thirty years to develop. Thirty years. The disease kills 600,000 people a year, almost all of them African children. When the vaccine finally arrived, the African Union had no manufacturing capacity to produce it. We had to wait for supply from European and Indian facilities. For a disease that doesn’t exist in Europe.
The pharma incentives camp explains this as a market failure. It is also a colonial continuity. The countries that extracted wealth from Africa for centuries now fund disease research as charity, on their timeline, with their priorities, and retain the intellectual property. The TRIPS agreement protects pharmaceutical patents globally. During COVID, wealthy nations blocked the TRIPS waiver that would have allowed developing countries to manufacture their own vaccines. The pattern is consistent.
The effective altruists calculate cost per life saved. We appreciate the math. We’d appreciate it more if the lives being calculated had any say in how the money was spent. The most effective intervention is sovereignty over your own health infrastructure. That doesn’t fit in a cost-effectiveness model.
Where we concede ground: Some international programs saved millions of lives. We can hold both truths.
What would change our mind: An eradication campaign designed and led by affected countries, fully funded, with IP transfer.
Read the full synthesis: Why haven’t we eradicated more diseases?