People are taking to the streets in the Haitian city of Saint Marc to protest the construction of a cholera clinic by Doctors Without Borders. Around 300 students and other people gathered to complain (and throw rocks), voicing fears that the clinic would bring more of the disease into the area. More than 280 people have died from cholera so far in the recent outbreak, according to U.N. figures.

Presumably, a well-regarded aid organization like Doctors Without Borders knows what it is doing and wouldn't contribute to the spread of cholera in Haiti by misplacing a medical clinic. As the Al Jazeera correspondent in Port au Prince said, the anger is primarily due to a lack of public education about the disease. That may be true, but I think there are probably other issues here. Haitians' suspicions of the clinic might have as much to do with their general condition as it does with the building itself.

It was more than nine months ago that a 7.0 magnitude earthquake hit Haiti, killing a quarter of a million people, leveling the capital, and setting back the country's infrastructure and economic development for years. More than 100 countries pledged about $15 billion to repair Haiti in the wake of the devastating earthquake. But so far Haitians have seen little improvement in their conditions. There are still 1.3 million people living in displaced persons camps, where hunger, rape, malnutrition, and now cholera are common. So far only $300 million of the $1.15 billion the United States appropriated to Haiti has reached the country.

Earlier this month Haitian protesters blocked off the area around the U.N. military installation in Port au Prince and carried banners that said "Down With the Occupation." In Mirabelais people are protesting that Nepalese U.N. forces nearby are contaminating the river with sewage. As long as reconstruction continues at such a slow pace, Haitians won't see the U.N. forces and international organizations as there to help. Some of that anger might even be taken out against much-needed medical clinics.

Writing in FP earlier this summer, former U.S. ambassador on global HIV/AIDS, Jack Chow, offered a glimpse into China's policy on the epidemic: When it comes to aid money, give a bit, recieve lots and lots. At the time of writing the piece, China's contribution to the global pool of donor money to fight HIV/AIDS, the Global Fund, was $2 million over eight years. Meanwhile, the country won an $1 billion in grants. For a country with $2.5 trillion in foreign currency reserves, this seemed a bit out of whack.

Perhaps they got the message. Because at the replenishment conference that took place earlier this week -- a gathering in which countries, foundations, and other donors pledge their committments for the coming three years -- China upped the ante. From $2 million annually, China's contribution rose to approximately $4.6 million, or $14 million over the next three years. That's still not terribly impressive (especially considering that Nigeria offered a not-dissimilar $10 million for the fund.)  

Still, the pressure was clearly on. Prior to the conference, six U.S. senators urged China to give its fair share. The Global Fund itself has also been pushing in this regard, urging the rising powers to slowly transition from recipient to donor. "China, Brazil and India should remain net beneficiaries the Global Fund," Kazatchkine told AFP. "[A]t the same time, they have to be contributors." That was one of President Barack Obama's administration's big goals in the replenishment as well: to get other donors to take up a fair share of the burden, particularly amid difficult financial times.

There were a few other interesting funding committments that stand out from the conference as well. The United States offered $4 billion over three years -- an increase from past funding but still not enough to please activists. Perhaps more interesting, however was the massive $300 million committment from the Bill and Melinda Gates Foundation. That number dwarfs almost all country donors -- including countries known for giving a relatively high proportion of their GDPs to aid, Norway, Denmark and Australia. What a new world it is where the richest foundation in the United States can outspend the world's most generous national donors.

Iraq is still paying the world back for Saddam's actions -- literally. The Christian Science Monitor reports that the Iraqi government has agreed to pay $400 million to American citizens who claimed to have been tortured or traumatized by the Iraqi regime following Saddam's 1990 invasion of Kuwait. With a 15-30 percent unemployment rate, ubiquitous violence, and a still lacking infrastructure, why is the new Iraqi regime paying so much money to American citizens when it was all Saddam's fault? Because the payment may help Iraq's case to end U.N. sanctions that have lasted since Saddam Hussein's rule: 

Settling the claims, which were brought by American citizens, has been seen as a key requirement for Washington to be willing to push for an end to the UN sanctions.

"There was a lot of pressure on the Iraqi government to do something that gets Congress off their back," says one senior Iraqi official, adding that the settlement cleared the way for US efforts to bring Iraq out from under the UN sanctions.

That's right, Saddam is long gone but sanctions on the still rebuilding country aren't. In fact, Iraq has already paid Kuwait $27.6 billion in reparations and continues to devote five percent of its oil revenues in accordance with the U.N. sanctions resulting from Saddam's invasion. While many countries have cancelled a lot or all of Iraq's debt to them, Kuwait continues to support Iraqi reparations -- regardless of the $22 billion Kuwaiti budget surplus for the last fiscal year.

So if U.S. citizens get paid by the Iraqi government for Saddam's "traumatizing" from 20 years ago, what will the United States pay the families of Iraqi citizens that are actually killed by U.S. forces? Well, the U.S. government is trying to find ways for Iraq to pay for that too.

Imagine for a moment that you're a government minister in a poor or fairly poor country. You've got a limited budget and you've also got a lot of work to do -- children are undernourished, you need to increase the numbers of them that go to school, and maternal mortality is leaving behind ranks of young orphans. Let's also say that, like most countries in the world, yours is a bit unequal. So here's the question: If you want to cut poverty rates, who should you target? The lower middle class -- the "low-hanging fruit" that doesn't have far to go? Or the most destitute of the population?

For years, the answer has been the former. It seems logical: If you can only spend so much, why not help the category that is closest to overcoming poverty? Surely, the most destitute have too far to go to benefit from the limited aid available. This is the approach that countries such as Nigeria, Ghana, Pakistan, and Vietnam have taken in recent years. And they have made some progress.

But you'd be wrong, according to a new study released today by UNICEF. Based on rigorous data tests from 15 countries, the researchers found that the best way to reduce poverty is to start at the bottom, not in the middle. And the difference is a lot. For every $1 million spent on anti-poverty measures, you would "avert 60 percent more deaths" if you help the poorest first, according to the study. The reason for this is simple: if you're destitute, and you recieve a bit of aid, say a cash transfer of $100 a month, that will boost your income by a massively larger percentage than if you are middle-income. Put in another context, if you are a women with no access to healthcare during childbirth, a trained midwife will mean much more to you than it would to a woman with basic care already.

This isn't wonky. It's big -- really big -- not least because it is something of a rethink of the way that governments, including the United States, have been doing development. One of the biggest focuses of the Obama administration's $63 billion Global Health Initiative, for example, is to build up health "systems" -- training healthcare workers, improving facilities, etc. This study says, that kind of thing is great -- but it's also not the most efficient solution. Health systems are usually not accessible to the poorest of the poor because of cultural barriers, poor transportation, or a pure and simple lack of information. Healthcare has to come directly to the communities.

This is, by the way, useful for another another global problem that has arisen in recent years: massive inequality. The world has lifted millions out of poverty (thanks to China and India mostly, but they weren't alone.) But those who remained poor have gotten poorer, and those who were rich have gotten richer. How great would it be if the way to tackle absolute poverty (the numbers of poor) and relative poverty (the inequality factor) was actually the same? Pretty great. As UNICEF Exectuive Director Anthony Lake put it today, "We have an extraordinary opportunity to do not only the right thing but the most practical thing."

Now, to convince the politicians...

Editors note: I am in New York this week on a generous fellowship from the United Nations Foundation, covering the lead-up to the Millennium Development Goals Summit at the U.N. General Assembly starting on Sept. 20.

Muammar Qaddafi has eradicated and restructured the Libyan calendar, publicly supported international terrorism and then called the Security Council the "terror council," ordered an entourage of virgin bodyguards and a Saharan camel to accompany him to public events, and even demanded that the U.N. abolish Switzerland.

So what's the next move from the maniacal megalomaniac? The most shocking of all: a random act of kindness. Colonel Qaddafi has personally procured a plan to save a fledgling Italian town, ostensibly harboring no motivation in the project aside from altruism and affection.

The fateful meeting between Qaddafi and his newly adopted medieval mountain town was love at first sight. Last year, while traveling to the G8 Summit, Qaddafi feared the recent 6.3 magnitude earthquake had weakened the infrastructure in central Italy and demanded his caravan take a detour. The new route took Qaddafi through the financially struggling town of Antrodoco, where the 2,800-person population showed him such warmth and hospitality that he reportedly declared, "You have entered my heart and I won't forget you." Promptly after his return home, Qaddafi sent his Roman ambassador and various other envoys to the village with promises of building luxury hotels, clean-water manufacturing plants, and a sports complex, and a general commitment to facilitating improvements in tourism and employment rates. A week-long conference to discuss the plans is now in the works.

It's a bit difficult to imagine Qaddafi and his motorway pulling around a mountain bend somewhere in Italy, the Libyan leader emerging from the depths of his flashy limousine -- decked out in his floor-length cape and Miami Vice-inspired G8 Summit suit, no less -- as Antrodoco's knight in shining armor. Then again, it was difficult to imagine him inviting five-hundred models to an evening out on the town, only to give each a personal copy of the Koran and attempt to convert them to Islam. Touché, Colonel -- you've surprised us again.

Not every day does Bill Gates lay the smack down on a sitting premier, but that was the case when the Microsoft founder slammed Italian Prime Minister Silvio Berlusconi's foreign aid policy. Berlusconi's stolen Italian headlines in the last week (but when is that not the case?) for a post-hair-transplant bald head -- and Gates couldn't resist making a not-so-subtle reference:

And in a clear reference to the notoriously image-conscious Berlusconi, Gates told Süddeutsche Zeitung: "Rich people spend a lot more money on their own problems, like baldness, than they do to fight malaria."

Italy's foreign aid budget was approximately 0.11% of its GDP in 2009, one of the lowest figures among developed countries, and half of what it was even in the prior year. Gates didn't mince words on his views:

"Dear Silvio, I am sorry to make things difficult for you, but you are ignoring the poor people of the world," he told the Frankfurter Rundschau.

Yesterday, I wrote about the brief life and presumed death of Rep. David Obey's "war tax," also known as the "Share the Sacrifice Act of 2010." Obey and his cosponsors hoped to make the Afghan war pay-go from here on out, with an income tax surtax (one percent for most earners, and higher for high earners) linked to the cost of war. 

I liked the idea precisely because so much of this war (around 40 percent) thus far has been funded with deficit spending during very good economic times, from 2001 to 2006, when high-income Americans certainly could have afforded higher taxes (which were cut by George W. Bush).

Commenters here and elsewhere asked: Why raise taxes during a recession, when the government has been deficit-spending wildly to boost the economy? Tax dollars are tax dollars, not earmarked for one use or another. Raising taxes is raising taxes. Isn't this precisely the time we're supposed to deficit spending? 

Well, yes, but not all deficit dollars are created equal, I fear. If we spend an additional $60 billion on the Afghanistan war, it does do some good for the American economy. It goes to American companies to build things like planes and armor, to hiring new soldiers, to American contractors working in Afghanistan to build roads and schools. But, down the road, the United States doesn't get those roads and schools. Soldiers stop fighting in Afghanistan, but continue to collect salaries and benefits. This means the deficit dollar spent in Afghanistan isn't as effective as the deficit dollar spent in, say, Detroit.

For some data on this phenomenon, Dean Baker at the Center for Economic and Policy Research produced a paper showing that war spending (rather than domestic spending) ultimately costs jobs and GDP.

But all of this might be moot. It seems that Congress is considering extending the estate tax, which was due to expire for a year before coming back into force in 2011. The tax only hits estates worth more than $3.5 million. I say extend it, and expand it to include less, erm, ample estates as well. That seems even better than the Obey plan. 

Over a million people die unnecessarily from malaria in Africa, according to a survey by ACTWatch. The group released a study of seven countries in Africa today, it found that most people in these countries are obtaining ineffective anti-malarials in the private market, due to the low availability and high prices of the far more successful Artemisinin combination therapy (ACT). ACT costs 20 times more than the older medications to which malaria has developed resistance. At about $11 it's 65 times more than the average daily wage in many of these countries.

Malaria needs to be treated with speed, explained Dr. Desmond Chavasse, speaking from the Pan-African Malaria conference being held in Nairobi. Children must receive medication within 48 hours of displaying malarial symptoms if they are to survive. This is why ACTs must get "out through the marketplace, so they are available at the end of the supply chain, in small shops, at affordable prices."

The study, funded by the Bill and Melinda Gates foundation, is intended to provide baseline information for a program that will subsidize ACT medication.

TONY KARUMBA/AFP/Getty Images

After many mumblings of foreign assistance reform in the works, some concrete signs came from today's Senate Foreign Relations Committee Hearing, "The Case for Reform: Foreign Aid and Development in a New Era."

That the Senate is holding such a hearing in the first place cause for applause. Once taboo, critiques of the U.S. aid system are now prolific -- coming from NGOs, academics, observers, and even the U.S. government itself. In fact, FP and Oxfam held a joint event to talk about just this last week. The flurry of discussion is clearly being noticed.

So what's wrong with aid? As Senator John Kerry put it in his statement,

[Experts] agree that too often decision-makers lack basic information about the actual impact of our development programs. They also agree that excessive bureaucracy and regulations and fragmented coordination are hampering our efforts to swiftly and effectively deliver assistance. And they agree that even as we plan for broad, fundamental reform, there are many steps we can take in the interim to dramatically improve the effectiveness of our foreign aid efforts."

Fixing all that is a tall order, especially with big domestic fish to fry (read: healthcare). But Afghanistan and Pakistan -- once again the first fronts on the war on terror -- bring these questions to the fore. There, the U.S. military is desperate to win hearts and minds, and helping out with roads, schools, hospitals -- in addition to security -- is one of the best ways to do just that. As the Counterinsurgency manual puts it, "military operations create temporary breathing space, but... long-term development and stabilization by civilian agencies are required to prevail."

So I, for one, am pleased that there are discussions ongoing -- and hopeful they'll be followed up with action. Read more about what the experts on the ground think needs fixing here.

ALI AL-SAADI/AFP/Getty Images

Writing in the Financial Times today, Rwandan President Paul Kagame makes a strong case against the "aid regime" as we know it. "The cycle of aid and poverty is durable: as long as poor nations are focused on receiving aid they will not work to improve their economies," he writes. He's piping in on a debate sparked by recent FP contributor Dambisa Moyo’s Dead Aid, which argues that Africa's prosperity begins when the inflow of aid ends:

"Some of Ms Moyo’s prescriptions, such as ending all aid within five years, are aggressive. But I always thought this was the discussion we should be having: when to end aid and how best to end it."

At first glance, this argument -- coming from Kagame -- strikes me as odd. Rwanda, and the president in particular, has garnered a reputation as a "darling" of Western donors over the last decade. Today, about 50 percent of the country's budget comes from foreign aid. And the number could rise. Last week, the country announced a funding gap of $47.4 million for its 2009/2010 budget, thanks to falling exports amid the global financial crisis. Where will that money come from? "[I]f Rwanda does not receive adequate grants, the ministry said, the balance of payments deficit could widen to $251.5 million," Reuters reports.

Then again, it's both fantastic and unsurprising to hear Kagame promising to wean his country from development aid -- through savy business ventures and smart economic policy. In fact, that's what the president has already started to do, and it's the reason that many consider Rwanda the emerging Singapore of Sub-Saharan Africa. The example is one to follow -- and not just in the developing world. 

Either way, Kagame's move is bold. His op-ed in the FT opens his governance and his country up to scrutiny, based on the standard he himself has set:

"No one should pretend that they care about our nations more than we do; or assume that they know what is good for us better than we do ourselves. They should, in fact, respect us for wanting to decide our own fate."

Let's hope he decides well.

PIERRE VERDY/AFP/Getty Images

The pledged $213 million for Somalia from Donors at a Brussels conference yesterday is a little short on details. Actually, it's devoid of details. The $213 million are meant to improve the country's flailing security apparatus, and boost a beleaguered African Union peacekeeping mission, AMISOM, from its current 4,300 personnel to a larger 8,000.

But all this raises some questions in my mind: 

1) How much of the money will actually come? Donors conferences are notorious for over-pledging and under-delivering. Already, $213 million is... peanuts in the scheme of things. For some perspective,  the Iraq war was estimated to cost about that much every DAY back in 2006.

2) Who gets the money? Presumably, the pledges will go through the new government, headed by President Sheikh Sharif. Presumably, tracing money through the bare-bones government created just months ago will be something of a challenge.

3) The money is set to be used to build up the existing Somali security force. But does a Somali Security service even exist? Many soldiers abandoned their posts after Ethiopian troops had trained them (but later failed to pay them) last year. So... how many soldiers are left? And will security -- rather than street-power by gun -- be their priority?

4) The money is also meant to boost an African Union peacekeeping force by another 4,000 or so troops. Sounds great, but where do they plan on finding those personnel? Countries in the region have been understandably loathe about sending their soldiers into a situation that carries a death wish. 

5) And finally, do the donors really care about anything other than pirates? Off the record of the formal conference conversations, it was piracy on the lips of the diplomats. If that's the case, the Somali government will find it hard to do much else with the money. Even something arguably useful like, say, paying their civil servants.

If we're serious about combatting pirates on land, this package looks a bit ridiculous. Unless, of course, there's something I'm missing. Dear Somalia, please help me out and send details.

2008 was the deadliest year on record for violence against aid workers around the world with 122 deaths:

Most of the violence occurred in three countries — Somalia, where 45 aid workers were killed, up from 7 in 2007; Afghanistan, with 33 deaths; and Sudan, with 19. Local humanitarian workers were most often the victims, accounting for 104 of the deaths. The study also found a significant increase in kidnappings over the past three years.

 Hat tip: Chris Blattman

Whoops:

President Bush Wednesday promised that U.S. naval forces would deliver humanitarian aid to war-torn Georgia before his administration had received approval from Turkey, which controls naval access to the Black Sea, or the Pentagon had planned a seaborne operation, U.S. officials said Thursday.

"The president was writing checks to the Georgians without knowing what he had in the bank," a senior administration official told McClatchy's Jonathan Landay. That would seem to be the larger theme here.

In today's Washington Post, Mike Gerson quite rightly lambasts the "Coburn Seven" -- seven Senate Republicans who are all but blocking expanded funding for the President's Emergency Plan for AIDS Relief (PEPFAR).

Unfortunately, what Gerson ignores is the GOP's long history of failure and ignorance on the HIV/AIDS front. This sad history dates to the very founding of the contemporary conservative movement. It was Ronald Reagan, the revered Godfather, who remained silent as tens of thousands of Americans died and a pandemic was spread to more than 100 countries around the globe. Even as Reagan did nothing to combat AIDS, his surrogates in the extreme right opined that the disease was a divinely-inspired retaliation on liberalism. It was Pat Buchanan, Reagan's White House communications director, who called AIDS "nature's revenge on gay men." Such sentiments proliferated as the power of the GOP's religious right-wing coalesced in the 1990s. Former Republican presidential hopeful Mike Huckabee, for instance, famously called for those infected with HIV/AIDS to be "isolated from the general population" in 1992. He stood by the statement in his 2008 presidential campaign.

When historians sit down to assess the modern conservative movement a generation or two from now, among the most severe tarnishes on the GOP's legacy will be Guantanamo and record deficits. There also will be the string of painfully ignorant policies the party has held on HIV/AIDS. To his credit, George W. Bush has probably done more than any conservative politician of his generation to reverse this tragic legacy -- more, perhaps, than any liberal politician, too. PEPFAR has provided life-sustaining anti-AIDS drugs to 1.4 million patients in the countries hardest hit by the disease. It may be the most favorably remembered foreign policy initiative of Bush's entire tenure. And in his January State of the Union address, the President proposed a long-overdue doubling of the effort.

It looked as though the GOP had finally found its moorings on combating a disease that, in a number of African countries, now affects more than 1 in 5 adults. But a small GOP minority once again appears poised to force the United States to take a backseat in the fight. As Gerson says, it will come at a price paid in lives. Unfortunately, it won't be the first time.