EA - How economists got Africa’s AIDS epidemic wrong by Justin Sandefur

Welcome to The Nonlinear Library, where we use Text-to-Speech software to convert the best writing from the Rationalist and EA communities into audio. This is: How economists got Africa’s AIDS epidemic wrong, published by Justin Sandefur on June 10, 2023 on The Effective Altruism Forum.I'm reposting this from the CGDev site, as I thought it might be interesting to EA folks (thanks to Ryan Briggs for the suggestion). For the short version, here's a twitter thread.In the 2000s, cost-effectiveness analysis said it was a bad use of money to send antiretroviral drugs to low-income countries—drugs that ended up saving millions of lives.Twenty years ago, in the same State of the Union speech in which he made the case for invading Iraq, George W. Bush asked Congress for $15 billion over five years for an ambitious new plan to pay for antiretroviral drugs for two million AIDS patients in Africa and the Caribbean.The President’s Emergency Plan for AIDS Relief, or PEPFAR, went on to become probably the most celebrated American foreign aid program since the Marshall Plan. An evaluation by the National Academy of Sciences estimates PEPFAR has saved millions of lives (PEPFAR itself claims 25 million). Impacts on total mortality rates across fourteen African countries were visible within just the first few years of the program (see figure 1). Separate research suggests the rollout of antiretrovirals, of which PEPFAR was a major component, explained about a third of Africa's economic growth resurgence in the 2000s.Figure 1. Adult mortality in PEPFAR focus and non-focus countries (from Bendavid et al 2012, JAMA)But at the time, some economists balked. The conventional wisdom within health economics was that sending AIDS drugs to Africa was a waste of money. The dominant conceptual apparatus economists use to evaluate social policies—comparative cost-effectiveness analysis, which focuses on a specific goal like saving lives, and ranks policies by lives saved per dollar—suggested America’s foreign aid budget could’ve been better spent on condoms and awareness campaigns, or even malaria and diarrheal diseases.“Treating HIV doesn’t pay”In a now infamous op-ed published in Forbes in 2005, before PEPFAR’s impacts were well documented, Brown University economist Emily Oster declared that “treating HIV doesn’t pay.” “It is humane to pay for AIDS drugs in Africa,” she wrote, “but it isn’t economical. The same dollars spent on prevention would save more lives.”In fairness to Oster and others, the phrasing here is important. Her argument was not that African HIV patients’ lives weren’t worth the cost—that retroviral drug prices exceeded the “value of a statistical life”, as economists might phrase it—but rather that if we take the budget as fixed, and the prices as fixed, the money could do more good if spent on other health programs.Oster wasn’t alone. While her delivery was perhaps deliberately provocative, her basic reasoning reflected a broad professional consensus, which viewed antiretrovirals through the lens of comparative cost-effectiveness analysis, and deemed them middling to poor value.A systematic review published in the Lancet in 2002, just as the Bush administration was privately plotting the PEPFAR announcement, found that in terms of saving “disability-adjusted life years” or DALYs, "a case of HIV/AIDS can be prevented for $11, and a DALY gained for $1” by improving the safety of blood transfusions and distributing condoms, whereas “antiretroviral therapy for adults, cost several thousand dollars per infection prevented, or several hundreds of dollars per DALY gained."Figure 2. Cost-effectiveness of interventions related to high-burden diseases in low- and middle-income countries (from Disease Control Priorities in Developing Countries, 2nd ed., 2006)In the 2006 edition of its authoritative volume on Disease Control Priorities in Developing Countries, the World Bank looked at 60 different health interventions to address “h...