The world remains polarized between the haves and have-nots at the start of the new millennium. The haves have access to health care, education, economic opportunities, while the have-nots do not. Globally, the haves number approximately 2 billion with the highest densities in North America, western Europe, Japan, South Korea, Taiwan, and Australia. The have-nots number 2-3 billion and are concentrated in Africa, the Indian sub-continent, parts of south-east Asia, and China. The remaining are struggling to prevent sliding into the category of the have-nots. While the numbers of haves are larger than ever before, the global community of the haves needs to assume responsibility for the welfare and the speedy uplift of the have-nots.
I would first like to address the question -- why should the haves bear any responsibility for the welfare of the have-nots? I feel there are many reasons, both humanitarian and long term survival of all, in addition to the fact that the haves are enjoying unprecedented prosperity and can afford to help. First, if we do not recognize the value of human life globally, then in times of stress or trouble it becomes much more likely that large numbers of people are deemed expendable. There are plenty of obvious examples of willful genocide in the twentieth century alone (Stalin's Gulags, the Nazi holocaust, purges under Mao in China, Cambodian killing fields, civil wars in Africa and Bosnia); and many more examples of such sacrifice by virtue of neglect. The most recent example in the latter category are the deaths due to HIV/AIDS in Sub-Saharan Africa.
The second reason is that the have-nots are doing jobs that technology has made obsolete. Contrast the difference between a construction site in India and the US. In India it is common to see fifty or more people moving dirt from one point to another and digging ditches and trenches, breaking stones to appropriate size or shaping and polishing sandstone, granite, or marble. In the US the materials are processed by machines and delivered to the site ready for use. Movement of materials and digging of the foundations is done by a few machines (front end loader, back-hoe, etc). The only way raw human labor can match the efficiency of machines is by sheer numbers who are paid barely survival wages, or if the builder does not have sufficient capital to buy the machines. Globalization is fast removing this latter limitation, and the rich are growing richer. For this reason the have-nots are a marginalized class -- they are not necessary for the survival of the haves, at least not in the current numbers. It is, therefore, easy to see why they are easily exploited, neglected, traded, and left to survive on minimal resources and without any hope for up lift. India today has somewhere between 300 to 400 million people in this category, of which 200-250 million subsist below the poverty line (UN and WHO estimates). Furthermore, I fear that due to nutritional deprivation, lead poisoning, and other environmental factors, a large fraction of this population may be mentally retarded to the point that it would be extremely difficult to educate them even with the best of intentions and resources. The question we must address, even if we accept the premise that this population is essentially condemned to a life of beasts of burden, is can we prevent this tragedy from repeating in coming generations?
The third reason is that the world's population growth is almost entirely within the have-nots (as a category, the oil rich middle-east countries are an exception). Unless we can stop the global population growth, the demand on resources to feed, cloth, and house the extra people will put further stress on the environment. We are already facing a crisis situation with respect to pollution, and the loss of natural habitats, ecosystems, biodiversity, and rain forests. There is also the likely possibility of global climate changes with catastrophic effects due to increase in greenhouse gases. To prevent this destruction and the way to population control (lowered fertility rates) lies in access to health care, literacy, female empowerment, and economic opportunities. In short, the solution to population stabilization is raising the have-nots into the ranks of the haves.
The fourth reason, which is simultaneously obvious and yet subtle, is that the long term welfare of the haves may depend on helping the have-nots make the transition. (The alternative is to watch them get eliminated by nature or strife). Countries whose populations contain a large fraction of have-nots often start becoming repressive. The political system becomes inefficient and corrupt. In the short term such systems serves the well to do, but in the long term, due to sheer numbers, the chances for rebellions and revolutions by the have-nots grow. It becomes easy for demagogues to incite communal, racial, and religious differences. With easy access to sophisticated weapons, such intrinsically unstable societies or nation states end up in wars that are brutal, quickly become killing machines that effect neighboring nations and may even draw them into the conflict, create enormous numbers of refugees, and then require very expensive, heart wrenching, and difficult relief and rehabilitation efforts. In addition to aggressive nation states with expansionist designs and despotic leaders, these societal factors are playing an increasing role in undermining attempts to guarantee international security and stability. Unfortunately, we humans seem to be much more ready to pay a huge price to clean up the mess than to prevent it.
Fifth, the have-nots are also the largest reservoirs for, and most susceptible to, diseases. We today have the understanding and capability to completely eradicate those communicable diseases whose only natural host are humans. These include HIV/AIDS, Hepatitis B and C; diseases which will destroy significant fraction of the most productive populations of Africa and Asia, and yet not significantly change the global population growth in the near future. To eradicate them requires money and political will (which are hard to generate if those at risk are considered expendable), health care, infrastructure for delivery, and education leading to behavior changes. With rapid air travel and tremendous growth in international tourism and commerce, the threat of communicable diseases is global; there are no safe havens. However, the have-nots suffer disproportionately as is evident from the HIV/AIDS crises: the developed countries have reduced and stabilized their rates of new infections, whereas the rates are still exploding in the developing countries.
Lastly, modern day transport and information technology has linked people around the globe. This has also made people in developing countries aware of what they are missing, that their talents would be far better rewarded in the developed countries. As more and more of the intelligentsia migrates from developing to the developed countries, they are bound to impact the social, political, and economic balance of the host nations and leave a vacuum in their own. Will these host nations learn, in time, to accept and thrive with a multi-cultural, multi-religious, multi-ethnic population, or will we again witness the horrors of racism and eventually of pogroms? Even more serious is the mass migration of the desperate, the impoverished, and the persecuted. As their ranks swell and they become more aware of a better world within their reach, will the developed world just close their gates and eyes? Can these nations continue to protect their current prosperity and not be drawn into, or be a party to, a genocide either directly or by neglect?
The challenges are huge and overwhelming. What we must, however, understand is, left unchecked, they can undermine the western civilization. It too will then go down in history as yet another great civilization that lasted two hundred years. Nation states seem to be so much more focused on building defenses to protect themselves from aggression by land, sea, air, and now space rather than on alleviating the root causes. Can creating cocoons really protect us from a raging fire storm of people? How many people need to die, be killed directly or indirectly, before we respond in a cohesive way and with adequate resources?
Historically, the socially enlightened have not had the knowledge nor the means to implement the necessary changes in a planned and holistic manner. They have done what little good they could, mostly in small areas and in a small way. This format created the paradigm of small scale limited intervention, which is still the dominant mode of operation of most foundations and even governments.
Religion and Marxist-Leninist-Maoist inspired experiment in socialism/communism have been two large scale efforts to change whole societies. Religious organizations have worked with the poor, provided them hope and a shoulder to lean on, but have not succeed in developing egalitarian societies (witness India, South America and Africa). In fact, in many cases it contributed to freezing societies into highly hierarchical structures. Socialism/communism failed because it violated the basic tenets -- of the people, by the people, for the people. Without political, social, moral, or religious checks, the rulers became an elite class, ruthlessly deciding, in isolation, what was good for the people.
Technology, natural disasters, wars and strife, and pandemics, rather than human design, have been the dominant drivers in the evolution of all species including humans. Clearly people created technology, however, their impact and effects on society were, in most part, neither anticipated nor planned. The important question is whether we now have the means and the tools to do so?
The big change that, I believe, has occurred in the last decade is that there now exist the resources and the capability to develop the tools to change the lives of the under privileged. Of the four drivers mentioned above we have little control over natural disasters -- we can only develop efficient and speedy procedures and infrastructures for crisis mitigation and remediation. It is hard to imagine that any person would want wars and strife to be the deciding forces in the future evolution of humanity, even though there is constant, costly and elaborate planning undertaken to figure out how to emerge as the victor in event of this possibility. While not wanting it, I fear that the lack of a massive relief effort to change the lives of the have-nots may make future wars and strife a regular occurrence. On the positive side, we have made giant strides in our understanding and utilization of technology and we certainly can, in principle, control communicable diseases. Even in the case of the diabolic HIV, it took only four years since the initial group of patients came to light in the US to identify the pathogen, understand the routes of transmission and how to stop the spread, and devise blood tests to determine the HIV status of a person. Furthermore, using awareness campaigns, the developed world stabilized the rates of new HIV infections within 10-15 years. Behavioral changes, like female empowerment, reproductive rights, optimal use of birth control methods are taking much longer. Technology and information exists, the knotty issue is how to use it wisely and how to implement the changes, especially in foreign lands and in unfamiliar cultures, without creating unforeseen problems. The knowledge and resources are concentrated in the developed world, while the challenges are in the developing world.
To my mind, the most important first step is to realize and accept the fact that any social intervention that results in changing behaviors is, in fact, an attempt at redesigning society. Societies are very complex organic entities. It is therefore essential to look at them as a whole, and examine all aspects of the society and individuals within the society when contemplating to change them. One has to understand the interdependencies and long term consequences of intervention and determine, with god like foresight, which aspects of society need change and which do not, and how long these changes will take to occur. One has to move societies from one stable ledge on a steep mountainside to another. Understanding how to do this redesigning (this sounds presumptuous and yet, in fact, is what I believe we attempt to do) is essential. Most current work, both in the field and in academics, tends to shy away from the label "redesign" if understood as a social engineering, i.e., creating a blueprint for an ideal society. There are plenty of historical tragadies to warrant disdain for such a thought. I would, therefore, like to make it very clear that by redesign I do not, under any circumstances, imply creating a blueprint for an ideal society, but mean creating a holistic and organic process that carefully considers the many interdependencies in the lives of people/society and works towards a sustainable and equitable future. I feel that if intervention is approached with a rational redesign as the long term goal, our efforts will be far more holistic and sustainable and involve minimal collateral damage. Such careful planning throughout when trying to change societal behaviors is, to my mind, the greatest challenge facing today's intelligentsia.
Societal behavior changes require considerable time (decades), occur best in a non-threatening environment, and people have to be able to see tangible rewards along the way. It is, therefore, essential to build trust first. This is most effectively done by addressing the problems of the day as perceived by the people, and not by inflicting an agenda upon them. To sustain the program requires developing a resilient and robust infrastructure for delivery. Milestones along the way should be such that progress made until then can be preserved even if the external funding were to disappear. I believe that it is the immensity of this challenge and the historic lack of tools that prevents people from thinking in terms of a holistic approach. Without such careful planning, changes caused by limited ``surgical'' intervention are often not predictable and can have severe negative consequences. I believe that with the revolution in technology, a much better understanding of the issues, and with the increase in resources, we may now have the tools to undertake the challenge of working with systems as a whole.
In order to develop long term, sustainable, holistic intervention, non-government organizations (NGO's), foundations, and governments have to first follow the advise they give to those in need of help -- change behavior! Two important changes are required. First, organizations should take a holistic approach rather than each focusing on one area like population control. (As discussed below population control requires the success of several key issues on which it is predicated). They must think in terms of transforming whole villages or group of villages, rather than intervening in only one aspect of people's lives. Second, different organizations and governments need to work together to do something really big -- the recent Gates-Turner-Rotary Club effort to eradicate polio is a welcome first step, but such vaccine mediated eradication of a communicable disease does not require behavior changes on the part of the recipients.
My discussions with the gurus of public health give me little hope that such a co-ordinated and large effort will happen in the near future. There is a reluctance to start something big in light of the immense literature on the pit falls and ``realities'' of life on the ground like the absence of adequate infrastructure. Also, something big will have to confront all the nuances of political sabotage and corruption. What I find, in general, missing or in very short supply are knowledgeable and caring people to implement programs. The gurus do not have the time to make personal commitments or to take ownership for bringing about change. They are mostly involved in apex organizations and too far removed from the actual work. Their approach, especially as advisors to foundations, tends to favor caution; undoubtedly they have had plenty of real life experiences to justify this caution. While such a cautious approach saves the foundations from getting involved with risky and fraudulent proposals, it also plays a large role in preventing support for or the development of any large scale activity. As a result we continue to have a multitude of ``studies'' and ``pilot'' projects that do not lead to a national size program. My feeling is that, due to the time-critical and desperate nature of many of the current societal crises, it is important that some risks be accepted in order to understand how to scale up successful ``pilot'' projects to national or even international size programs.
I believe that primary health care and education are the two key issues that deserve utmost priority. They are also, in many ways, least prone to debate on their long term impact on development and sustainability. One would argue that these two issues are what the World Bank, WHO, and the UN have also pursued vigorously; which raises the pertinent question -- what is new in what I have to say? I differ in two aspects. The first is in the implementation and the subsequent involvement of these apex organizations once the funding has been provided to nation states. The implementation is failing because all money that these organizations give is only to the national government, which, in India, then distributes it to the state governments, and from there to various organizations, both government and non-government. Unfortunately, at every level inefficiency and corruption, hallmarks of poorly governed countries, work to whittle down the funds. The effective throughput is small, projects are poorly run, and the good ones are grossly under funded. (A prime example of such failing programs is the 22000+ primary health centers that are supposed to provide health care to people in rural India). In addition, the monitoring by the apex organization is poor. These apex organizations have themselves become huge bureaucracies, consequently the planners have little contact with actual work on the ground. Also, the monitors of programs have gotten accustomed to ``air conditioned'' luxury while on the job. They don't spend any significant time trying to make projects work; they are driven by deadlines to meet and reports to file. Also, they have little vested interest or ability to make the projects work as planned for very often they are not the innitiaters or planners. This sad situation has lead to a widespread lack of trust and confidence on both sides; the fundamental pre-requisites for behavior change at both the individual and societal level. It is this lack of trust and confidence that has made the problems seem impossible to fix, and why even the gurus have become skeptical and doubt whether anything can be done unless there is a major change in the government. I believe there is tremendous hope at the grass-roots level as there are many caring, committed and well-meaning people who could achieve a lot if they got resources and help. It is high time that such large international organizations find ways to give money directly to organizations that do the work and not keep supporting government programs that are failing. Two example of good models that work are Medecins sans Frontieres and the Grameen Bank.
My second suggestion is that the conventional educational curriculum (learning the three R's) should also include, with the same priority, awareness on health, environment, and other societal issues and focus on the development of life skills needed to deal with today's complex society. An example of a life-skills that should be included in the educational curriculum is teaching students, very early in life (3-8 grades) and especially girls, how to manage money. This skill alone will significantly address the issue of female empowerment as documented by the success of the microloans to women by the Grameen Bank in Bangladesh. To deliver this education, I believe, increased emphasis should be placed on visual learning, aided by today's revolution in information technology. While such holistic education is particularly needed for women for reasons commented on below, I believe women's status in society will improve most rapidly if the education addresses the immediate needs of both sexes simultaneously. For example, when boys and girls learn how to manage money, through the medium of games and classroom activities, it also develops mutual respect and co-operation between the sexes that they can draw on in later years.
In many parts of the world today, women are second class citizens. Female empowerment, reproductive rights, and access to health care and education for all are four goals that few would question and are essential from a moral, ethical, and humane point of view. They are also essential pre-requisites for societal development, and especially for the transition of the have-nots to the haves. Furthermore, these issues are very highly correlated and achieving these key goals will furthermore lead to population stabilization, significant decrease in the risk of communicable diseases, and to economic development. Of these four issues, the latter two are very dependent on resources, while the first two requires societal behavior changes. Female empowerment and reproductive rights are the most difficult to achieve and controversial. (While women, clearly, are the primary sufferers, my belief is that the goals will be achieved much sooner if solutions include joint programs or parallel programs for men that address related issues). Strategies for their implementation within the many highly disparate societies are not fully understood. Nevertheless, any society that achieves these goals will be very different from what it is now. Thus, one cannot escape the fact that such a society would be highly transformed. If this transformation is planned and occurs with little collateral damage, then that process is what I would call successfully designing society. My hope is that while we understand how to create such a holistic process and develop the tools, we should not wait to take action but make primary health care and education goals to achieve within the next decade.
To conclude, I feel strongly that the plight of the have-nots is so severe that one must think in terms of large scale holistic intervention. Our efforts will succeed if we act cohesively, and face and overcome the fundamental issues with care, understanding, and sustained commitment towards the welfare of all.
Rajan Gupta