good afternoon i'm alessandro barbera from la stampa the daily we are here today with michael kramer and together we will be discussing one of the most relevant topics of the current trento festival edition for years we have discussed in italy about providing vaccines to our children after decades we are now discussing whether vaccines are harmful or not and for some of us this has become almost a fight we heard recently about the death threat to mr briony a doctor at this arafail hospital in milan who has been fighting to have vaccines being administered to all children so while we are discussing in italy about one of the major advances of the 1900 in other countries taxes are still far to come according to unicef data out of the 7.6 million infant debts that means infants below five years of age that occur every year in the world so most of these are due to acute respiratory diseases measles and today mr kramer is going to talk about the warmth so it's one of the most relevant diseases in the african countries all such diseases can be easily fought against with nets with the vaccines with simple prophylaxis most of which are unknown to people living in low-income countries but the same applies to drugs drugs that be used to treat these diseases that can that are really accessible to citizens around the world with the exception of again low-income countries mr kremer is definitely the right person to talk about this topic mr cramer is a gates professor or developing society at the economics department of howard is a member of a number of associations and mr kramersby focuses research on health education and water uh in poor countries and latin american countries he was awarded several prizes and one of the core points of his research study is the use of incentives to lead people in the low-income countries accepted to be vaccinated mr kramer contributed to the advanced market committee to foster private investment across the world on research on vaccines and their distribution in the poorest countries at the end of 2010 it was appointed director of the most important u.s agency to support poor countries he works with numerous organizations devoted to poverty he's one of the founders of world tech an organization that enrolls a young students and researchers who are willing to teach for a certain period of time in the poorest countries around the world today mr kramer will try to give an answer to the following question is it right to have the poor countries pay for health what is normal for us what is almost a duty for us that is to say contributed to the national health system to pay for the everybody's health and allow everyone to be treated in other countries in the poorest country particular this is a real issue because the question is whether it is useful to pay for health care there are numerous studies showing that in a number of cases paying even a small fee discourages a prevention in poor countries so the question that mr kremer will try and give an answer to is whether well first of all how prevention should be carried out in the in poor countries how health policies have to be approached especially in african countries and whether it would be possible to introduce incentives if there are incentives that really work to again attract people and lead them to accept preventive treatment to save millions of lives in these countries professor cremer will deliver a speech that will last roughly 40 45 minutes at the end the q a session will follow you will have the opportunity to ask questions also please write them down now thank you very much so some of the deepest health inequalities are inequalities between countries so uh whereas in rich countries people can expect to live to their 70s or 80s in some cases in poor countries it's some poor countries it's even in the 40s there's there are cases where uh out of every thousand children uh who are born uh more than a hundred uh and before until recently many more than that would die before they became age five there's many people dying of preventable diseases for which vaccines exist there are people dying because they don't have safe water and like but what i'd what i'd like to talk about today is not focus only on the deep inequalities that exist but also on what practical steps can be done to address them and in fact there's a huge amount that can be done to address them so let me just illustrate that principle by showing you the case of of of incomes and life expectancy in the united states in 1900 and in vietnam in 2009 so you can see the us in 1900 is much much richer than vietnam was 2009 that would still be the case now but if you look at life expectancy life expectancy in vietnam is actually quite good much much better than it was in the in the u.s in 1900 so how does vietnam how is vietnam able to achieve this remarkable health performance at a at very low income levels well there's been a fundamental shift in the possibilities to generate health since since 1900 there are many in historically the big killers were infectious diseases and still in poor countries infectious diseases are a major major source of death but we have many very cheap very effective technologies that can they can solve these problems uh or at least greatly improve them things like vaccines like antibiotics like water treatment programs like for malaria insecticide treated nets and that's what it's those sorts of things that create at least the possibility to substantially reduce the inequalities across countries in in health but as i just said many people in low-income countries don't benefit from these technologies children who should get vaccines or not are not all getting them some countries have very high immunization rates but others like india or nigeria have much lower immunization rates uh i'll talk some about the case of water today um but i what i'd um would like to do is to start out with the standard economic model of this the standard economic model one standard economic model at least sees investment in health as a form of investment that's the human capital model of health so in that model people will invest on their own as long as the benefits exceed the cost now there might be a case if you stuck to that standard economic model there might be a case for the government to subsidize health because if i get a vaccine not only do i protect myself but i also maybe prov i don't infect others and that creates a very standard economic logic for subsidizing prevention of communicable disease but it would also depend on are people will people's behavior be affected by the subsidy if people's behavior won't be affected by the subsidy then maybe a subsidy isn't so warranted it also depends you have to finance that subsidy from somewhere if raising the taxes causes big distortions in the economy then that would also suggest maybe the subsidy should be smaller if it doesn't cause big distortions maybe it could be larger so let me illustrate some of these points by looking at the case of worms worms that affect humans so i'll so about 1.5 billion people around the world have in in low-income countries are affected by one of two broad categories of worms soil transmitted helmets uh that's hookworm whipworm uh roundworm um and schistosomiasis also called bihar's in school-aged children are particularly susceptible in part because sometimes these worms enter through the feet and children are less likely to be wearing shoes they also are very important in transmission because adults are more likely to defecate in the latrine but children may defecate outside here's this is uh some pictures of some soil transmitted humans and then the harzi is different it's it has part of its life cycle and snails so it's particularly prevalent near freshwater sources this is a picture of snails near lake victoria out in kenya so the worms can affect nutrition because they absorb some of the food that the human eats they can cause anemia that in turn has been shown to have cognitive effects the effects depend on the intensity of infection if you just have one worm that's probably not going to cause noticeable symptoms but if you have a lot of worms in your body then you'll have bigger effects and the distribution is very skewed as a a lot of a lot of some a lot of people have just a few worms some people have very heavy loads and it depends also on the prevalence in the society so there's unanimity in the medical profession that if somebody's infected it's a it's the standard of care to to treat them the medicine's uh known to be efficacious it's safe it's also very inexpensive so these these medication is routinely given in very large quantities to farm animals uh to to help them gain weight that's uh standard it's very very heavily used but while farm animals are getting them many people are not and one of the reasons for that is that whilst the medicine is very cheap like two cents per dose in fact although for for the many of the companies are now giving it away for free um the diagnosis is expensive you have to test a stool sample you then that's expensive it's imprecise and it's logistically very difficult because you have to get the stool sample test in the lab find the same person again and get them the treatment so the world health organization has long recommended that in places where there's high uh prevalence of the disease more than 20 percent or or more than uh or they there'd be treatment once every year and where it's more than 50 percent multiple treatments per year usually two and that's been considered to be highly cost effective by a number of of organizations okay um i wanted to talk about some some research that i was involved in in this i'm going to give three examples the first one is worms then i'll talk about a water example and then i'll talk about a vaccine example so on the worms example i was involved in an evaluation in kenya there were 75 schools there's high prevalence in this area so we found we found big effects but they might be smaller in other settings the the program 25 school there was a small ngo doing this work they began the the treating the children for worm in 25 schools then they went on to another 25 schools and then on to another 25 schools and the order in which they did this they basically put them in made a list of the schools and then counted off one two three one two three one two three to find out which group who would be treated what so here's a picture of the deworming day at the school the the teachers uh administer the drugs these are very simple and safe drugs who the world health organization says teachers can recommend them can provide them as long as they're trained by by health personnel um so we first analyzed the short-run effect of this and we saw the worm infections went down but then much to our surprise i don't say much to our surprise but we weren't necessarily expecting this at the beginning but we found reduced infection among untreated children in treatment schools so not all the children got treated but even the ones who didn't get treated seem to have have lower prevalence and also people attending other schools within three kilometers we initially thought it went down to six kilometers but we had a programming mistake so it only goes out three or maybe four or five kilometers but but not six the we also saw an increase in school participation when the children were treated so they were for every child treated you got 8.5 percentage points higher enrollment or higher school participation a combination of higher enrollment less dropout and greater attendance among those still so this has been you can compare this to other programs designed to increase school participation and it looks very cost effective so this is a chart from j pal where they looked at various approaches for increasing school attendance and and you can see that i think i can't read the numbers from here but i believe that's 12.5 for every 100 that's spent on deworming there are 12.5 additional child years of school so it's very very cheap to increa to get an additional year of school through this now some of these other programs i should be clear they're very i actually think the other programs that look smaller are also very good programs so i don't think you should only only uh try to keep children in school when you can do it this cheaply uh um these are all uh cases in africa here's something in uh in south asia again the tallest bar there is a it's a combination of this type of combination of deworming and uh iron provision okay so and i should say that in our initial study we saw that children were going to school more but we didn't see any evidence of cognitive improvement it wasn't that they were smarter it was just they were spending more time in school but a follow-up study by osher looked at the younger children in the area so they would have benefited not directly they didn't get the medicine if they were just you know very young because they weren't at school but they might have benefited from the lower transmission of the disease in their community and what he found was that for the very young children the children who are still undergoing child development their brains are still developing he saw an improvement in cognition as well quite substantial particularly for children whose older siblings themselves got they got the program okay so i've recently been involved in a long run follow-up of this and what we found is that is quite substantial long-run effects effects that actually seem to differ some by gender so for males um we see that they're they're they're they're working more hours so they're not these kids are now young adults they're in their 20s typically so they they increase their late their hours of work by 17 percent um that's so one thing to note is there's low hours of work in this community um because among these young people they're farmers and there's not certain part of the year there may not be that much to do so except unless you move into say a manufacturing job where there's more i don't want to think these are not high-end manufacturing jobs so very low-end manufacturing jobs we also saw higher earnings so about a you know 24 percent increase in earnings um we they were also more likely to work in manufacturing