This was not a big issue in the campaign . . .

. . .but it's certainly been a big issue here. Somewhere on President Obama's lengthy agenda is the question of foreign aid. In case it isn't already obvious (and I suppose I should add a caption) the world map at the top of the page shows life expectancy at birth. It is stolen from the Global Education Project, and one of the tasks I still need to do in building the new site is to add the credit and link. I have recommended the site here before, I reiterate it now.

As you can see, your chances of stayin' alive are worst in much of Central Africa and a few places in Asia -- for Americans, it's important to note that Afghanistan is among them. Iraq is probably also doing worse than the map shows, but we don't have good up to date information.

One of the few initiatives for which the soon-to-be former administration has gotten widespread credit is PEPFAR, the President's Emergency Program for AIDS Relief. The $3 billion a year we spend on PEPFAR is a bit less than the president originally promised, and it has been compromised somewhat by idiotic conditions regarding condoms and abortion, but it has certainly made a big difference, especially in Africa. PEPFAR has provided antiretroviral treatment to 1.45 million people, and is credited with preventing 10 million babies from being born with HIV.

However, as Colleen Denny and Ezekiel Emanuel point out in the Nov. 5 edition of JAMA, there are many other far less expensive interventions that we do not fund adequately, which could save even more lives and prevent more disability. For the $3 billion a year we spend on PEPFAR, providing antiretroviral therapy yields a benefit of somewhere in the range of 5 million Disability Adjusted Life Years. (I talked about that concept recently, and promised to get back to it. So here we are.)

But providing insecticide treated bed nets to prevent malaria, for the same money, would provide more like 200 million DALYs. Just providing the standard set of immunizations for kids would yield 429 million. A community based support program for pregnant women, using trained lay midwives and inexpensive supplies, gets us 333 million DALYs.

PEPFAR has support in the U.S. because we are familiar with HIV and its ravages, and there is a strong advocacy community in the U.S. for HIV prevention and treatment. But the many other deadly afflictions of poor countries, for which we could have an even greater impact at less cost, are comparatively neglected. Given the hard times we'll be going through here -- hard by our standards but not hard at all by the standards of the poor countries we're talking about -- it will be difficult for the new president to increase spending on foreign aid. Alas, Denny and Emanuel seem to argue for allocating funds away from PEPFAR and toward some of these other problems.

I can't support that because the last thing we need to do right now is divide people who support assistance to the poor countries. But there are compelling reasons for us to do more. Yes, Africa does not need an increase in it's human population. But we know that when infant mortality goes down, and the status of women improves, birth rates go down and population stabilizes. So the right strategy can work.

Just one more item on a long, long list.

Oh yeah: For the benefit of our Alaskan readers, Africa is that big continent to the south of Europe. If you aren't sure where Europe is, leave a comment and we'll tell you how to find it on the map.