How to help the poor: piecemeal progress or strategic plans? The White Man's Burden: Why the West's Efforts to Aid the Rest Have Done So Much III and So Little Good William Easterly. Penguin Press, 2006. Pp 400. US$2795. ISBN 1-594-20037-8.

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The White Man's Burden has one basic motif: that large-scale plans to help the poor through increased foreign aid are bound to go awry. According to William Easterly, there is too much corruption in recipient countries, unaccountability in delivery mechanisms, and sheer uncertainty about what to do. Rather than aiming big, with comprehensive and well funded strategies, Easterly thinks it is better to aim small and piecemeal, making progress one gradual step at a time-"the right plan is to have no plan", he asserts. Aid should be as he imagines markets to be: without plans but filled with "searchers" looking for piecemeal progress. Searching is, of course, needed to identify best practices for foreign aid. But so too are plans, at local, national, and international levels, to take those best practices to scale.

Easterly seems to misunderstand the historical record on aid, and, far more unfortunately, to misjudge what's possible in the future. His main methodological error is a failure to make careful distinctions across countries and types of aid programme. By neglecting to hone in on what has worked and failed in the past, Easterly conveys a misplaced sense of helplessness in the face of massive but solvable problems.

The critical fact is that much is known about how to help the poor. As The Lancet helped to show in its 2003 series on child mortality, the know-how and technologies exist to save lives each year by the millions, and to improve livelihoods by the tens or hundreds of millions, but only by expanding beyond piecemeal approaches and applying knowledge at scale. The same conclusions were reached in two reports that I helped to direct for WHO and the United Nations in 2001 and 2005, respectively, both of which are roundly criticised by Easterly.

The White Man's Burden opens with an upside-down account of recent innovations in the control of malaria-a portrayal that exemplifies Easterly's unreasonable antipathy to bold strategies of action. A considerable body of research has shown the efficacy of long-lasting insecticide-treated nets to prevent malaria and reduce the number of cases of complicated, and hence often fatal, malaria. Yet markets alone will not deliver these nets. The poorest of the poor simply can't afford the product ion costs of US$4-7 per net plus the added shipping and distribution costs. Aid is needed to ensure that bednets reach the impoverished and vulnerable populations.

A few years ago, donor agencies began subsidising the sale of bednets, a process known as "social marketing". A special focus was put on antenatal clinics in impoverished rural areas. Yet even this strategy has shown massive limitations, because it mainly covers children of pregnant mothers who have access to antenatal clinics and can afford the subsidised price of the bednets.

After widespread calls by malaria experts for much more extensive coverage of bednets, UNICEF, the Red Cross, and other donors are now teaming up with ministries of health in low-income countries to distribute the bednets for free in the course of national immunisation campaigns and through health facilities. Such efforts have recently been tried with great success in Ghana, Togo, and Zambia, and will be carried out in many other countries as well.

Easterly rejects this approach, since it smacks of "planning". He reports with disdain that when the nets were handed out for free in Zambia, "70 percent of the recipients didn't use the nets", whereas with social marketing in Malawi, the coverage of nets rose from 8% in 2000 to 55% in 2004. Yet this account completely distorts the facts. When I tracked down Easterly's source (which is not cited in the book), it turns out that in a campaign of less than 1 week covering several rural districts, the free distribution programme in Zambia raised household coverage of nets from 28.9% before the campaign to 85% after it (American Red Cross and CORE, Malaria case Study Partnerships in Action: An Integrated Approach to Combining a Measles Campaign with a Bed Net, Vitamin A and Mebendazole Campaign in Zambia, July, 2004). Of the households that received the nets, 97.1% still had their nets after 6 months, when a follow-up survey was done. Moreover, a remarkable 60% of the children and pregnant women in the recipient households used the net in the night before the survey. Thus, in less than 1 week, the Zambian campaign led to a coverage rate of about half of all children younger than 5 years, while the social marketing approach in Malawi arrived at roughly the same coverage rates in 5 years. Even these increases in coverage rates are likely to rise as the procedures on free net distribution and the follow up with households are further improved. Successful national-scale free distribution campaigns are underway in several more countries.

For decades, interventions in public health and in agriculture, such as Asia's Green Revolution in food production, have shown that the combination of a sound technology, a plan for large-scale implementation, adequate financing, and steadfastness over several years can make huge inroads against disease, poor health, and hunger even in the poorest settings. Bold plans have been part and parcel of those successes, contrary to Easterly's core theme of piecemeal solutions. Successes include the UNICEF campaigns to expand coverage of immunisation, the eradication of smallpox, the control of onchocerciasis in Africa, the campaign to eradicate polio, the scaling up of antiretroviral medicines, the use of oral rehydration therapy, the global application of DOTS for tuberculosis, the expansion of family planning and contraceptive coverage, and the spread of high-yield variety seeds. In all of these cases, remarkable progress has been possible, even in the most impoverished countries and often in war zones. The limiting factor to even broader success has too often been the scale of financing. Naysayers have always abounded. The 1967 plan to eradicate smallpox was widely viewed as impossible and a waste of money. It only narrowly passed the vote of the World Health Assembly. A decade later, the last natural case of smallpox was reported.

Easterly argues against increased aid for plans at national scale, yet in the end he acknowledges that aid has often worked. Towards the conclusion of the book, Easterly makes a fine statement that closely parallels the recommendations of the UN Millennium Project, a project whose recommendations he professes to reject:

"Put thefocus back where it belongs: get the poorest people in the world such obvious goods as vaccines, the antibiotics, the food supplements, the improved seeds, the fertilizer, the roads, the boreholes, the water pipes, thetextbooks, andthe nurses. This is not making the poor dependent on handouts; it is giving the poorest people the health, the nutrition, education, and other inputs that raise the payoff to their own efforts to better their lives."

The book would have been useful if it had explored this correct idea, showing in detail the volumes of aid and practical planning at all levels-international, national, and local-that will be needed to achieve these results. Such results are indeed achievable, but the path to success will not be found in Easterly's unhelpful volume.

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"By neglecting to hone in on what has worked and failed in the past, Easterly conveys a misplaced sense of helplessness in the face of massive but solvable problems."