di Giovanni Mottini - Università Campus Bio-Medico di Roma

The landscape of development aid

The social, economic and human situation of developing countries (DCs) is increasingly becoming a source of concern for international public opinion. However, it is not a question, it is worth emphasizing, of a rekindling of his sensitivity for the chronic ills afflicting these countries, but of a growing unease in ascertaining that everything, despite everything, seems to stubbornly go wrong. Today Africa holds all the negative records: Gross National Product, external debt, industrialization, exports, calories and per capita income, life expectancy, infant mortality, literacy, environmental degradation, violation of human rights… In reality they are many now realize that this "despite everything" has left much to be desired in the past years and there are also many who speak of the need for a profound critical review of the commitment to development, not only in its means but also in the spirit which animates it.

Everyone agrees in the observation that the welfare model cannot represent the way for the liberation of peoples from poverty.

On the other hand, recent events such as those still underway in the Great Lakes region have demonstrated, once again, all the limits of the emergency policy. Limits not of a technical-logistical nature but of a strategic and political nature which have resulted in an objective untimeliness in the face of the humanitarian catastrophes that one was called upon to face, if not even in authentic political-diplomatic impasses while the tragedies of hundreds of thousands of human lives they wore out inexorably.

The panorama is disconcerting and disheartening.

Faced with all this there is a first, immediate lesson that can be drawn, and that is to be careful not to fall into what could be briefly called "the logic of taking things for granted".

The typical banality is recognizable by the fact that it is an affirmation that is clearly right and universally acceptable but, on analysis of the facts, invariably unsatisfactory. A paradigmatic example is given by the statement: "prevention is better than cure". With a more or less refined phraseology this expression occurs in all the godschiaraintentions of the representatives of national and international humanitarian aid organizations, and this for a long time now. It even constitutes an intentional premise and an operative rule. On the other hand, the ofchiaration of Alma Ata was also born to be the practical translation of principles like this.

Another "discount" is represented by the saying, now widespread: "to those who ask you for a fish teach you how to fish". In fact we want to underline, with an expression of which common sense is clear to everyone, the need to go beyond the logic of the simple satisfaction of a need, to instead transfer knowledge and tools that transform the need into an opportunity to overcome of one's limits, in the acquisition of a know-how which is an indication of progress; that is precisely of a human development.

The same priority as human resources; a "discovery" that has been made almost everywhere, starting with the American-style business culture and therefore borrowed from the science of human development, risks being taken for granted in the face of the observation that educational and training strategies for developing countries they seem to have too little and ephemeral impact when compared to the social and political upheavals to which these peoples are perennially exposed.   

But why does what is right as a principle end up being taken for granted?

The reasons for a failure

There are operational strategies, organization charts, schemes and protocols that have been on paper for decades now and, based on the experience gained, all the corrective measures necessary to make them applicable have already been introduced.

In fact, in terms of health care, agricultural and industrial development in developing countries, it can be stated that there are no particularly innovative solutions and strategies to develop and those formulated have all the necessary elements to be effective. On the other hand, even with a superficial analysis of the results, the great disproportion between the resources employed and the results obtained is evident.

All that remains is to note how the Third World, "despite everything", continues to look like a ship without a rudder. That "despite everything" tells us precisely that the right principles have not had the expected effectiveness, to the point of losing most of their value and being reduced to discounted operating models.

It is clear then that there is a distortion in the system. Something similar to what, in lingThis statistical change is called, with an Anglo-Saxon term, bias. It is the presence of a factor, a systematic error, capable of totally altering the veracity of a result, of a way of interpreting reality.

What, then, is the systematic error capable of frustrating most of the efforts for a balanced development of humanity?

If we replace the adjective "discounted" with "emptied", which is, to a large extent, a synonym, we have a possible key to interpreting the phenomenon we are analyzing. Indeed, one gets the impression that behind these principles, or perhaps better said, within these principles, there is a conceptual void which is the main reason for their inconsistency and ineffectiveness. This void is essentially referable to the lack of an authentic anthropological content, that is, of a science-knowledge of man, of his being and of the purpose of his action. Without this content, in fact, the reading of reality is inexorably flattened on the analysis of facts, data, indicators. In fact, the logic of indicators (of health, well-being, development), elaborated to represent reality and make it more measurable, is far from exhausting the meaning of events and even more from understanding their causes and, consequently, identifying the real solutions to problems.

The ethics of human development

The road is that of the rediscovery of the sense of the event with respect to the number, to the statistics, to its technical-scientific analysis. Beyond, therefore, even the same material cause of the events.

There is no need for other periphrases to understand that all this means, once again, the affirmation of the primacy of man against those anthropological reductionisms which have invalidated Western culture and conditioned human development.

But even the simple affirmation of this primacy (how many times has it been proclaimed in all possible circumstances and venues?) cannot suffice to give a complete answer to the "crisis of meaning" which ultimately represents the most appropriate diagnosis of situation we are examining.

 It becomes necessary, as we said above, to propose to discover the meaning of human events. Talking about the meaning of a human act means talking about its purpose, that is, its why and, it is worth emphasizing, its for whom. As the Austrian psychiatrist Vicktor Frankl stated, with a splendid and daring intuition, the result of his experience as an intellectual, a prisoner in Nazi concentration camps: "one can also live without knowing why, but one can never live without knowing who one lives for" . "Why" and "for whom" are the essential components of the analysis of human action. There is no doubt that, up to now, the "how" to act has prevailed. But, beyond the protocols of behavior and the definition of objectives, man cannot do without, due to his nature, to seek the profound motivations of his actions and, therefore, of living from him.

The conclusion is that development, as a human phenomenon, is immediately a moral, i.e. ethical, phenomenon.

Such a conception, if taken to its logical consequences, implies a radical change in the basic strategy of human development. Radical change really means going to replace the roots of the entire system. Not its external apparatus, therefore, which retains its validity, but the origin of that systematic error, of that distortion that we have identified in the void of purpose and meaning, that is, in the anthropological void.

This ethical perspective of development takes on an extraordinarily effective role when it is translated into the key factor of human formation. Everywhere, in development cooperation programs, training is mentioned since its importance has not escaped development analysts, but it is very rare to find in training programs for knowledge and skills, drawn up for the personnel of developing countries, an education (in the Latin sense of educere, to bring out) to the motivations of human promotion. Once again it is a matter of asking the questions of why and for whom: why and for whom to learn, why and for whom to do, why and for whom to improve?

Man needs these answers, even more when he seems to know how to live without them. Precisely then, in fact, when the need is culturally less expressed, it means that the need for it is stronger.

An intent of ethical training of this magnitude presupposes the existence of a profound and authoritative ethical cultural deposit. Its scarce presence and influence in the panorama of western culture is the main cause of its non-application. The reality is that Western culture, called to play a leading role in development, suffers the consequences of an ethical impoverishment that makes it incapable of proposing an authoritative model of man and humanity.

Biomedical knowledge and human development

As often happens in a logical system, when one of the components is deficient, other components of the system risk experiencing a sort of hyperplasia which, frequently, becomes difficult to control. Scientific progress in the biomedical field has made enormous strides in the last fifty years and precisely in this passage of the century, and of the millennium, it appears increasingly evident that the "health sciences" represent the sector of knowledge that most contributes to forging a new model of society. A society which, not surprisingly, is defined as "biotechnological" due to its most decisive characteristics. Some observers, particularly attentive to that virtual and sophisticated representation of our society which is the Internet, have in fact underlined the fact that one of the most active and promising sectors of the network market is precisely that of human health, in all its aspects.

We are not interested now in investigating the problems of a strictly bioethical nature that new technologies are opening up: in vitro fertilization, genetic manipulation, cloning, genetic discrimination; some already current, others very close to come. Rather, we are interested in developing a reflection that arises upstream of these facts but which, not for this reason, ceases to be of a strictly ethical nature.

Towards the beginning of the eighties, still driven by Dichiaration of Alma Ata, the WHO launched the slogan "Health for all in the year 2000". This objective, although legitimate and desirable, not only appeared almost immediately unattainable but, if we look at the trends dominating the world of biomedical sciences, it is even evident that the opposite objective is being achieved: a level of "excellent health for a increasingly restricted circle of people” with the consequent widening of the gap in the quality of health care between Western countries and developing countries. About a year ago, Médecins Sans Frontières launched a campaign for "Access to Essential Medicines" which, among other merits, also has that of bringing some particularly eloquent data to the public's attention: every year there are 17 million deaths due to infectious diseases, more than 90% of cases of infectious diseases and deaths due to these diseases in the world are recorded in developing countries, 20% of the world's population has 80% of the world's production of medicines. Data from the world of therapeutic research are even more suggestive than the current trend: 0.2% of pharmaceutical research concerns serious infections of the respiratory system, tuberculosis and diarrhoea, whereas 18% of deaths are attributable to these diseases; from 1975 to 1997, out of 1233 new drugs patented in the world, only 13 (ie 1%) concerned the treatment of tropical diseases. Here is precisely the imbalance, the hyperplasia of one part of the system and the hypoplasia of the other part.

On the world stage, biomedical progress therefore appears more and more like a sort of greenhouse where luxuriant plants grow, with surprising and beneficial flowers and fruits, but located in the middle of a vast garden left almost uncultivated. Most of the efforts and resources are devoted to developing the plants in the greenhouse, but most of the inhabitants of the garden cannot access them and must be satisfied with the meager wild fruits of the garden, almost abandoned to itself…

Proposals for cultivating the garden

Nowadays, therefore, the panorama of biomedical knowledge and, more generally, that of human health seem to represent the paradigm ofingsocial justice in the world. It is no coincidence that the metaphor of the garden and the greenhouse can be conceptually brought closer to that of MacLuhan's global village, which has become the paradigm of the phenomenon of globalization, and shows the distorting effects, at a planetary level, of a system of knowledge that proceeds detached from the needs ethical and anthropological aspects discussed above.

Whoever governs the progress of this progress is by no means unaware of what is happening. References to the need to transfer the benefits of biomedical progress achieved in the West to the urgent needs of the populations of developing countries are increasingly frequent.

The WHO Director General, Dr. Gro Harem Bruntland, said, for example: “We must invest in the future in the development of new drugs, new vaccines, new diagnostic tools. Our commitment must be to create the incentives and adequate economic conditions to combat the diseases that today determine and perpetuate poverty. Research and development are decisive tools of this strategy”.

The European Union has embarked on a vast strategy to fight [1] against the so-called Poverty Related Diseases (PRDs: AIDS, tuberculosis and malaria above all) - which mainly affect developing countries - through the creation of North-South partnerships for the implementation of trials clinicians on the pathologies that fuel the vicious circle of poverty-sickness.

Recent scientific advances are in fact giving new impetus to the possibilities of intervention against PRDs and against a large corollary of other pathologies. Research on the genome of humans and other living organisms, including, for example, malaria parasites and their vectors; the suggestive results obtained from immunology and ethnogenetics have significantly increased the possibility of conducting targeted experiments on these pathologies.

The novelty of this strategy lies precisely in the willingness to support and involve the medical profession in developing countries in research programmes. This involvement is in fact perceived as an unavoidable condition for guaranteeing the effectiveness and duration of the interventions over time.

In fact, we have realized the need to address the serious health problems of developing countries not only with the supply of drugs and material resources, which risk turning out to be blunt and inadequate weapons, but above all with the transfer of knowledge and skills that contributes to bridging the still existing professionalization gap and which constitutes, in these countries, a less obvious but equally substantial brake than that of technical means, to the achievement of satisfactory results in the fight against diseases.

Therefore, once again, the adequate response to the problems of human development is found in formation. But is it enough to plan training as a vehicle for development, to transfer knowledge to the local interlocutor so that the hoped-for transfer of benefits from biomedical knowledge is achieved where it is most needed?

If we must record the positive fact of the maturation of the awareness of the world community regarding the moral need to carry out this communication of knowledge and transmission of benefits of biomedical progress, on the other hand there are quite evident signs of the purely technical drift of this transfer of goods. In other words, we fall into the phenomenon, already highlighted above, of a flattening of knowledge to the specific dimension of know-how. Training understood in this way is reduced to "making someone capable of doing something", including discovering how to better treat diseases, giving little content to the dimension of why and for whom I work. Once again, there is the risk of a major distortion (a bias) of the system capable of ingengender a new "obviousness": that of an increasingly biotechnological North that makes the fruits of its scientific progress available to, sooner or later, defeat the diseases of the South of the world.

For a social ethics of medicine

How to avoid this new distorting effect?

It was said that development, even before being a technological phenomenon, is a moral, ethical phenomenon. And this is because it is the result of a complex of human acts, yesingoils and collectives, which contribute to the creation of situations which, from time to time, promote or oppose - and often with a mechanism of repeated omissions - the dignity of the human person and of entire peoples.

The first step therefore cannot be simply operational. It requires reflection; ethics, indeed. What must first be examined is the goal of biomedical progress, even before the way in which I propose to pursue it. It is outside of itself - one could say, paraphrasing Godel's theorem - that it finds its raison d'etre. The ethical dimension to be satisfied is not only that of the legitimacy or otherwise of a scientific procedure or biomedical research, but also that of human choices which lead to the allocation of the economic resources available for biomedical progress in one direction rather than in an other. In this sense it must be recognized that the world of research is by no means independent in the choice of where to direct its efforts. The market logic that invests in research and development to obtain economic profits has an absolutely preponderant weight. And this logic remains far from setting humanitarian goals.

All this makes the commitment by the world of culture a priority for the promotion of a social ethics of medicine; the ethics of the choices that concern the good of the health of a community by now to be understood in a "global" perspective, that is worldwide.

Therefore what is more urgent is not so much the technological formation of the "local interlocutor" of the developing countries, on which the emphasis is being placed, but rather the humanitarian formation - which means ethical and anthropological - of all those who are or they will be called upon to govern the development of biomedical knowledge in the industrialized West.

It is a task that must first of all involve those places that their own vocation are dedicated to research and the transmission of knowledge: first of all, therefore, the university world and in particular in those components most directly involved in the dynamics of global health: the faculties of medicine, biology and pharmacy, but also that part of the economy that increasingly deals with the world of health.

In fact, the anthropological reductionism which serves as a premise for the development of health policy strategies and which tends to interpret the fundamental rights of the human person - theingonly the individual but also entire peoples - through the prism and the measure of his ability to produce and which invalidates and condemns every initiative for developing countries to unsatisfactory or contradictory results.

The university and cultural world therefore have the delicate and fundamental task of informing biomedical knowledge of those ethical and anthropological principles that are necessary to give the thickness of a third dimension to the technical and scientific content that characterizes and composes it.

If this task already exists in the very context of Western culture, faced with the frequent threats to respect for human life that an improper use of this knowledge brings with it, the prospect of cooperation with developing countries enriches it with a strong social footprint in a global key and "global" which confirms and makes more manifest its inalienability.

 

[1] European and Developing Countries Clinical Trials Program on Poverty Related Diseases: EDCTP