by Robert Guest
Ramaphosa argues that that state-driven black empowerment will make the economy grow faster and so benefit everyone.28 This is unlikely. Where contracts with black firms make commercial sense, white firms are likely to sign them without compulsion. The marginal effect of making such deals compulsory is to force firms to sign the contracts that they would not otherwise have signed, that is, the ones that do not make commercial sense.
Under pressure from the government, firms in some industries have drawn up “black empowerment charters,” typically promising that, say, 25 percent of the industry will be in black hands by 2010. To achieve this, they will have to sell chunks of their businesses to blacks. The government insists that such deals will be made at “market” prices, but the market price of an oil firm or a mine is obviously affected by the fact that its owners are obliged to sell it. White firms submit because they fear that the alternative might be worse. They would rather surrender a quarter of their business now than have the whole thing nationalized in ten years’ time.
But black business cannot rely on handouts forever. As a proportion of the total, South Africa’s white population will shrink for the foreseeable future. The white birth rate is lower than the black one, and many whites are emigrating. Older whites, whose houses and savings are tied up in South Africa and who cannot afford the rent in London or Sydney, tend to stay. But the young and gifted, who do not see why they should be punished for their parents’ crimes, head for countries where they can learn new skills, earn hard currency, and not be discriminated against. Some will spend a few years abroad, gain marketable experience, and return to South Africa’s sunshine and cheap restaurants. But others will not.
Some South Africans rejoice at the “chicken run,” arguing that emigrants are traitors – and probably racists, too – so the country is better off without them. But if South Africa is to prosper, the dwindling number of white taxpayers needs to be replaced by a black business class that is not dependent on the government for its profits. Someone has to pay for all those public works programs.
South Africa has a better shot at creating a genuinely entrepreneurial black business class than most other African countries. The roads in South Africa are better, the airlines run on time, and all the support services that businesses need are in place, more or less. What is missing is a wider understanding that wealth is something you have to create.
In late 2002, I found myself sitting at a table with South Africa’s mining minister, Phumzile Mlambo-Ngcuka, and a group of up-and-coming black mining barons. She was trying to persuade me that a proposed forced march to black mine ownership would be good for business and good for the country. She sensed that I was not convinced.
“Why are you so cynical?” she asked.
I glanced to my left, at a suave representative of the new black entrepreneurial class who was sitting there. It was Bridgette Radebe, a cabinet minister’s wife.
Conclusion: One Step at a Time
A Tanzanian child began to shake uncontrollably. The doctor guessed, correctly, that she was in the grip of malarial convulsions. But the child’s mother diagnosed that her daughter had been seized by evil spirits and, knowing that if the doctor gave her an injection to calm her, those spirits would escape through the needle-hole and possess more victims, she clasped the girl to her chest and fled from the clinic.
The clinic staff were aghast. If the child was taken back to her village, she would surely be subjected to the traditional “cure” for convulsions, where the victim is put under a blanket and made to inhale the smoke from burning elephant dung until she passes out. This would probably not address the underlying cause of her sickness, namely the millions of malarial parasites cavorting in her bloodstream. So they chased after the mother and persuaded her to return to the clinic by promising that her daughter would not be given an injection. Instead, they gave her a tranquilizer, Valium, via a suppository. When the shaking stopped, they were then able to give her quinine to tackle the parasites, and she was cured.
I was told this story by Harun Kasale, a Tanzanian doctor, who was trying to explain some of the difficulties of delivering medicine to the poorest of the poor. Many rural Tanzanians believe that diseases have supernatural causes, which prompts them to seek supernatural remedies. Instead of trusting conventional medicine, they turn to traditional healers. Some traditional treatments may have healing properties, but many are useless and possibly dangerous. They remain popular, however, not least because they tend to be much cheaper and nearer than the nearest clinic.
Dr. Kasale was trying to make it easier for rural Tanzanians to get proper health care. He was working on a ponderously named scheme with a simple premise: the Tanzania Essential Health Interventions Project (TEHIP) set out to show that even a tiny health budget, if spent rationally, could make a big difference.
Backed by the Tanzanian health ministry and a Canadian charity called the International Development Research Centre (IDRC), Dr. Kasale and his colleagues carried out an experiment. They took two miserably poor rural districts, with a combined population of 700,000, and tried to find out how many lives could be saved by budgeting more logically. The results were so startling that I flew out to Tanzania to have a look.
The experiment was conducted in Morogoro and Rufiji, two sprawling slabs of bush the size of Belgium. I landed in Dar es Salaam, the commercial capital, and drove out westwards to Morogoro with Dr. Kasale. It was as beautiful as poor rural areas usually are. Coconut palms glistened in the morning mist, dazzling sunlight played on green-cloaked mountains, and every ten-dollar shack had a million-dollar view.
The people in Morogoro live much as they have since agriculture first reached Tanzania, growing starchy vegetables, eating what they need, and trading the surplus, if any.
Before the experiment began, annual health spending in Tanzania was about $8 a head. In Morogoro and Rufiji, IDRC added $2 a head to the pot, on condition that it was spent rationally. By this the donors meant that the amount of money spent on battling a particular disease should reflect the burden that disease imposed on the local population.
This may sound obvious, but it is an approach that few health ministries take, in Africa or in the West. In Morogoro and Rufiji, no one had a clue which diseases caused the most trouble, so TEHIP’s first task was to find out. The traditional way of gathering health data in Tanzania was to collate records from clinics, but since most Tanzanians die in their homes this was not terribly accurate. So TEHIP sent researchers on bicycles to carry out a door-to-door survey, asking representative households whether anyone had died or sickened recently, and if so with what symptoms.
These raw numbers were then crunched to produce a “burden of disease” profile for the two districts. In other words, researchers sought to measure how many years of life were being lost to each disease, with a weighting to reflect the collateral damage to families when breadwinners die. They found that the amount the local health authorities spent on each disease bore no relation whatsoever to the harm that the disease inflicted on local people. Some diseases were horribly neglected. Malaria, for example, accounted for 30 percent of the years of life lost in Morogoro, but only 5 percent of the 1996 health budget. A cluster of childhood problems, including pneumonia, diarrhea, malnutrition, measles, and malaria, constituted 28 percent of the disease burden but received only 13 percent of the budget.
Other conditions, meanwhile, attracted more than their fair share of cash. Tuberculosis, for example, accounted for less than 4 percent of years of life lost but received 22 percent of the budget. No one wanted to cut spending on anything, but the research suggested that the extra $2 a head would be best spent on neglected diseases for which there were cost-effective treatments or preventive measures. As it turned out, the extra cash was ample: neither in Morogoro nor in Rufiji was the system able to absorb more than an additional 80 cents or so.
This tiny cash infusion smoothed the transition to a more effective approach to health care. Health workers, mostly
nurses or paramedics rather than doctors, were given a simple procedure to show how to treat common symptoms. An illustration: if a child arrives coughing, and with a running nose and a hot brow, the nurse is instructed to work through a checklist of other symptoms to determine whether it is merely a cold or something worse. If the child is breathing more than fifty times a minute, for example, he is assumed to have pneumonia, given an antibiotic, and checked again after two days.
In most cases the cheapest treatments are offered first. Children with diarrhea are given oral rehydration salts, which cost a few cents. If the salts don’t work, the child is referred to a clinic and put on a drip. For malnutrition, the first treatment offered is advice on breastfeeding. When this is not enough, the child is prescribed cheap vitamin-A pills. AIDS is tackled through education, condoms, and antibiotics to heal open sores caused by other venereal diseases, which present the virus with an open door into a new bloodstream.
Knowing which diseases people are actually suffering from enables clinics to order the right drugs. Previously, the government sent out the same package of pills to all dispensaries, which meant that popular drugs ran out while others gathered dust. Non-malarial mountain villages used to receive as many malaria drugs as mosquito-infested lowland ones, and villages where no one had ever suffered from asthma received asthma medication. “We did things blindly,” a doctor in Morogoro recalled.
Perhaps most important, health centers in Morogoro now encourage people to use bednets impregnated with insecticide, which fight mosquitoes in several ways. If the bug hits the mesh, it dies. If it merely flies close to the bednet, it feels dizzy and either falls to earth, where it is eaten by ants, or buzzes off to rest and recuperate, which means that it will bite no one that night. A bednet’s mosquito-repelling effect stretches for 500 meters in all directions, so netless villagers gain some protection from their better-equipped neighbors.
Conservative types at first shunned bednets in favor of the mtuti, a hot, itchy traditional sleeping bag woven of palm leaves. But with a bit of urging from nurses they discovered that cotton bednets are softer on the skin and better at beating back bugs. Despite the cost – about $3 for a locally made net, with the insecticide somewhat subsidized – the nets are popular. Village shops sell them. Peasants hang them in huts on stilts in their rice-fields, where they sleep during harvest season, so as to be at hand to scare off crop-munching hippos. In Morogoro, even the Masai, a fiercely conservative tribe of nomadic cattle-herders, have started draping themselves in insecticide-soaked bednets when sleeping under trees.
The results of all this were stunning. In Rufiji, infant mortality fell by 28 percent between 1999 and 2000, from 100 deaths per 1,000 live births to seventy-two. The proportion of children dying before their fifth birthdays dropped by 14 percent, from 140 per 1,000 to 120. The figures for Morogoro are thought to be equally good, although they had not been properly checked when I was there. In nearby districts, and in Tanzania as a whole, there is no evidence of a similar improvement over the same period.
The stories I heard in Morogoro suggested that better health care had made people less poor. Everyone agreed that the fall in malaria had had especially happy effects.
Like most of Tanzania, Morogoro is a holiday camp for mosquitoes. While Dr. Kasale and I were there, we were caught more than once in booming rainstorms. When each downpour stopped, it left stagnant puddles everywhere, which swiftly became hatcheries for mosquitoes. The locals stay dry-ish by using big palm leaves as umbrellas but until recently had little protection against the swarms that follow storms.
I asked people if their lives had changed since the TEHIP experiment began. They all said they had. A young peasant called Mustapha Dangeni told me that his two children used to be smitten with fever almost every month before he got a bednet. Now, he said, they had been healthy for a whole year. He and his wife had found that, because they did not have to spend time nursing sick children, they could work longer in their fields, so they had produced more spare corn and millet. They earned more money than usual and did not have to spend any of it on anti-malarial drugs. Dangeni invited me into his hut to show me all the things he had bought with the extra cash: a radio, a bicycle, some rough furniture, better tools, and so on. “Things are continually improving.” He beamed, leaning shirtless against a sack of charcoal.
Health and efficiency
The lesson from Morogoro and Rufiji is that simple ideas, rigorously applied, can yield dramatic results. Africa’s problems are huge but, if tackled rationally, not insoluble. The Tanzanian government is keen to roll out TEHIP-like programs across the whole country. That would be a good start. Other countries should follow suit. And they should also apply the same rational approach to more or less everything they spend money on.
Too often, they won’t. Governments everywhere waste money, but in Africa the problem is especially grave because there is less cash to waste and because it is wasted so flagrantly.
Given finite funds and potentially infinite demands for them, a government has to decide what is really important and what is not. Needs vary from country to country, but most African countries still need the basics: primary education, primary health care, passable roads, piped water, and a functional legal system. Such bare necessities should be given priority but often aren’t.
Even in the most indebted countries, there is always money for ministerial limousines and mansions or for first-class flights to pointless conferences. After an unexpected upgrade on a plane bound for Lusaka, I once found myself sitting next to one of the top men at the Zambian finance ministry. When he found out who I was, he spent the next half an hour hectoring me about Zambia’s need for deeper debt relief, before the complimentary champagne put him to sleep. Around that time, his country’s annual budget for dealing with its AIDS crisis was half the sum earmarked for building villas for heads of state attending a talking-shop Zambia was hosting.
In 2001, some 18,000 delegates gathered to trumpet their grievances and demand “remedial measures” at a “UN World Conference Against Racism” in Durban. Some Africans and black Americans demanded that compensation for slavery should be paid by the American government. Others demanded that reparations for the Rwandan genocide should be paid, also by the American government. Several African presidents dwelt at great length on the iniquities of colonialism while omitting to mention their own countries’ current ethnic violence.
In itself, the conference was not important. But it did highlight two big problems. First, the tendency of African elites to spend other people’s money on themselves – a suite at one of the hotels on the Durban waterfront does not come cheap. Second, their tendency to believe that Africa’s problems are someone else’s fault.
I hear this argument often, at least from the educated middle class: civil servants, politicians, academics, journalists, and so forth. African newspapers are full of it, as is my email inbox. A good way of keeping up with the trends in this school of thought, I have found, is to subscribe to the New African, a glossy magazine published in London. It makes fascinating reading.
The latest issue to land on my desk contains the following. An editorial denouncing the “secret groups” from “the nations of European stock” who “meet each year and fix the rules and order of the world.” An article praising Robert Mugabe’s land reform program. Another installment in a long series on German massacres in Namibia around the beginning of the twentieth century. An article on the American presidential election of 2000 entitled “So who stole the black vote in Florida?” A piece on water privatization in Ghana, subtitled “Why does the West want to take away from the people the most precious and indispensable commodity of all – water?” A book review arguing that “the current geopolitical order … has ensured that Africa [is] at the eternal mercy of the big powers and their multinational corporations.” And a report that a Cameroonian doctor has discovered a cure for AIDS.1
The magazine’s editor, Baffour Ankomah, a Ghanaian with a colorful
turn of phrase, acknowledges that many African governments are corrupt and undemocratic but seems to resent it when foreigners point this out. If an African leader is particularly vilified in the West, Ankomah tends to applaud him for standing up to the neo-imperialists. When interviewing such leaders, Ankomah’s journalistic scepticism tends to fail him.
In the issue of July/August 2002, for example, he devotes the magazine’s cover and sixteen inside pages to a “ground-breaking world exclusive interview” with Charles Taylor, who at the time was the president of Liberia. Readers are assured that the piece is “a collector’s item” and treated to a dozen shiny pictures of Taylor, snappily suited, comfortably enthroned, and parrying tough questions such as, “How has life been at the top, as the democratically elected president?”
While it is quite true that Taylor was elected, one feels there is a bit of background missing here. In 1989, Taylor led a rebellion against the corrupt and murderous regime of Samuel Doe. After an eight-year civil war, during which soldiers in Mickey Mouse masks played “guess the sex” of unborn babies before cutting their mothers open to see, Taylor emerged as the most powerful warlord in Liberia. An election was held in 1997, which Taylor won by making it clear that if he lost he would start fighting again. “He killed my ma, he killed my pa, I’ll vote for him,” ran one of his campaign slogans.
Two years later, a new civil war broke out, pitting Taylor’s government against rebels backed by neighboring Guinea. Taylor’s ability to fight back was hampered by UN sanctions imposed on his regime for supporting the hand-chopping rebels in another neighboring country, Sierra Leone, and for his alleged involvement in the illicit trade in “conflict diamonds.”
