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Cuts with consequences

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Michael Gerson
April 8, 2011
— So far in the budget debate, the Obama administration has drawn few bright lines, preferring to blur distinctions with concessions. But last week, a neon line was drawn by an unlikely administration official.

Rajiv Shah, the administrator of USAID, possesses the mildest of manners. Testifying before the House state and foreign operations subcommittee, however, Shah had this to say:


“We estimate, and I believe these are very conservative estimates, that H.R. 1 would lead to 70,000 kids dying. Of that 70,000, 30,000 would come from malaria control programs that would have to be scaled back, specifically. The other 40,000 is broken out as 24,000 who would die because of a lack of support for immunizations and other investments, and 16,000 would be because of the lack of skilled attendants at birth.”


This is the hardest of hardball politics—accusing budget cutters of unwitting complicity in the deaths of children. House GOP lawmakers responded angrily.


“Nearly every administration witness appearing before the Appropriations Committee,” said Rep. Jerry Lewis, R-Calif., “has put forward nightmare scenarios and dire numbers to argue why we should not be reducing spending in any program. Republicans won’t be drawn into a debate over what might happen based on speculations and hype.”


But it is not realistic to take credit for cuts while forbidding a discussion of their consequences. Republicans were drawn into this debate when they proposed major reductions in foreign assistance, believing this category of spending to be an easy political target. Instead, they have stumbled into what one poet called “a problem on the borderline of ethics and accounting.”


By way of disclosure, I was an advocate within the George W. Bush administration for creating the President’s Malaria Initiative, designed to reduce mortality by half in 15 affected African countries. Most who die of malaria are children younger than 6—several hundred thousand a year in sub-Saharan Africa. I recall one in particular—an infant, her head covered by a cloth, carried by her mother out of the gates of a hospital in Uganda, among the loneliest sights I’ve ever witnessed.


This background allowed me to see how anti-malaria programs are designed. The interventions—insecticide-treated bed nets, new combination drugs, indoor spraying—are neither complicated nor controversial. It is possible, with some accuracy, to determine how many lives will be saved at a certain level of spending. Which means it is possible to determine how many lives would be lost at a certain level of cuts.


USAID estimates that reductions proposed in the 2011 House Republican budget would prevent 3 million malaria treatments. Because the disease is misdiagnosed about half the time, this means about 1.5 million people in need of treatment would not receive it. About 3 percent of untreated malaria infections progress to severe malaria—affecting 45,000 children. Of those children, 60 percent to 73 percent will not survive, yielding between 27,000 and 30,000 deaths. This does not take into account the 2.8 million children who will go unprotected by bed nets and insecticide spraying. Similar estimates can be made concerning cuts to immunization programs.


Despite Lewis’ claim, global health programs are not analogous to many other categories of federal spending, such as job training programs or support for public television. A child either receives malaria treatment or does not. The resulting risk of death is quantifiable. The outcome of returning to 2008 spending levels, as Republicans propose, is predictable.


Fiscal conservatives tend to justify these reductions as shared sacrifice. But not all sacrifices are shared equally. Some get a pay freeze. Some get a benefit adjustment. Others get a fever and a small coffin. This is not fiscal prudence. It is the prioritization of the most problematic spending cuts—a disproportionate emphasis on the least justifiable reductions. One can be a budget cutter and still take exception to cuts at the expense of the most vulnerable people on earth. In Britain, Prime Minister David Cameron is pursuing even greater austerity while increasing funding for development.


Cuts for global health programs should be of special concern to those of us who consider ourselves pro-life. No pro-life member of Congress could support welfare savings by paying for abortions. No pro-life member of Congress could support Medicare savings by cutting off life support for the sick. And it should give any pro-life member pause to support minuscule budget savings that risk the death of children from malaria.


Michael Gerson is a columnist for the Washington Post Writers Group; email michaelgerson@washpost.com.

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