Author of Mapping Mars

Dear Mr President,

Your number one priority in science and technology should be a new commitment to international public health. It is not a particularly sexy topic; it needs no new nano-know-how, nor a radical change in our way of seeing the physical world. It will create no great technical advantage for America, nor add to its already impressive defenses. Though it will employ the talents of hundreds of thousands around the world, relatively few of them will be on the cutting edge of research. But it is what you must do, nonetheless.

I, like you, am a believer in progress. And it is for that reason that I expect our descendants in a century or two to look back on our age and hold us in contempt. Not for the fact that we fought wars; some wars need to be fought, and some wars are hard to stop. Nor for the fact that we polluted the environment; we are, after all, becoming aware of the problems we have been storing up, and we are beginning to address them on many levels. Our descendants will despise us for having been content to live in a world where millions of poor people died each year for want of basic medical interventions that the rich half of the planet took for granted. And they will be right to do so.

Half a million women die each year because of complications surrounding pregnancy and childbirth; 99% of those women are in low and middle income countries. Saving the vast majority of them requires nothing more than providing trained birth attendants. The 1.6 million children in poor countries who die every year from measles, tetanus and pertussis could almost all be saved by the provision of simple vaccines, and if vaccines were developed against some of the other diseases that kill poor children—diarrheal diseases and diseases of the respiratory tract—that number could be doubled.That's without starting on malaria, which kills over a million a year on its own. Vaccines against malaria would be a great boon, and should be a high priority—but even interventions available today, such as insecticide impregnated sleeping nets and drug treatment, could save hundreds of thousands. Aggressive extensions of existing tuberculosis treatment programs could save millions more each year .

Some of your other advisers will tell you that there is no quick fix for any of this—that the best medicine the poor of the world can get is economic development, which slowly raises health standards in its wake. They are wrong. It is possible to achieve impressive health gains in very poor countries if the will and the resources are there. There is good reason to believe that improving the health of the poor makes subsequent economic development faster and more certain—and helps plant the seeds of stable democracy.

This is not to say that the problems can be solved simply with money and supplies. New interventions will be needed—most sorely vaccines against AIDS and malaria. And much will need to be done to build the capacity of health care systems to serve the poor. But that is not an intractable problem—it has been solved in various ways in various places. Evidence of a real commitment among rich countries to providing the necessary resources would galvanise public health workers around the world to take up those solutions and invent new ones of their own. The idea that spending on aid is necessarily wasted is a cynical and self-serving lie. If you don't believe me, ask Bill Gates.

Other advisers will tell you that the American people will resent money spent overseas when many are uninsured at home. Feel free to tell them that you have some plans for dealing with that problem too. Feel free to tell them that there will also be many benefits to spending money on the health of the poor; that it will grow new markets and win new friends, improving America's image both among those who benefit from this new generosity and those in Europe and Japan suddenly obliged to match it. But tell them too that you are doing this not for those reasons, but because it is the right thing to do.

And tell them that the American people are not as small of heart or mean of spirit as they imagine. Tell them that the American people will understand that the annual $8 billion budget you intend to have set for this program by the end of your second term is less than one percent of what America spends on health care. Tell them that every American couple that leaves a maternity ward with a healthy baby will be happy to think some of their money is making sure a mother in Africa doesn't bleed out unattended. Tell them the opportunity to change the world does not come often—and that as such opportunities go, this one is cheap.

I wouldn't want you to cut other science and technology spending to this end. But if you were to decide that was the only way to balance the books, then I would say go right ahead. The end purpose of research is knowledge with which to improve the human lot. At the moment we already have the knowledge we need to save hundreds of millions of lives over the coming decades, and if push were to come to shove for a few years, using that knowledge should be a higher priority than storing up more knowledge for the future .

You and I, as believers in progress, have faith that the future will be able to take care of itself. We must turn our attention to the present.

[This advice draws on work for the WHO's Commission on Macroeconomics and Health summarised in "Improving the Health of the Global Poor", Prabhat Jha et al, Science 295 2036-2039, March 15 2002]

Oliver Morton
Author of Mapping Mars