This paper was prepared for Stanford University’s Global Food Policy and Food Security Symposium Series, hosted by the Center on Food Security and the Environment, and supported by the Bill and Melinda Gates Foundation.

Sub-Saharan Africa (SSA) is home to two-thirds of the world’s ultra-poor today. This paper offers current thinking on the structural causes of the spatially concentrated, persistent ultra-poverty that has plagued Africa for a generation and some key entry points for facilitating Africans’ escape from persistent ultra-poverty.

The increased recognition of persistent ultra-poverty has rekindled long-dormant interest in poverty traps. The essence of a poverty trap is that there exists one or more low equilibrium level(s) of well-being in which people appear caught unnecessarily. Small adjustments fail to move people out of those equilibria sustainably. Rather, systems must change, major positive shocks must occur, or both. And in the absence of systemic change, recurring adverse shocks only drive more people into the trap.

The ultra-poverty trap that characterizes much of rural SSA today is intimately caught up with (i) the bidirectional interrelationship among hunger, ill-health, low productivity, weak institutions and natural resources degradation, all of which become manifest in low incomes, (ii) poor initial conditions associated with health and nutrition, especially early in childhood, but also with the state of infrastructure and the natural resource base on which rural livelihood disproportionately depend, and (iii) uninsured risk exposure, which is especially severe in rural areas and in agriculture. The closely coupled nature of these problems adds substantially to the challenge of addressing any one of them on its own and thereby makes integrated strategies essential. 

The available theory and evidence suggests that the policy focus must fall squarely on stimulating a smallholder food productivity revolution. Toward that end, the paper concludes by identifying and explaining key entry points for assisting the escape from persistent ultra-poverty in sub-Saharan Africa.

1. Build and protect the productive asset endowments of the ultra-poor
2. Improve the productivity of the ultra-poor’s current asset holdings
3. Improve risk management options for the ultra-poor
4. Facilitate favorable transitions out of agriculture

Although the topic of persistent ultra-poverty would seem to lend itself to a pessimistic ending, the future for Africa is actually rather hopeful. The East Asian experience demonstrates that mass, rapid escape from persistent ultra-poverty is feasible. Real agricultural output growth rates are accelerating in SSA, nearly doubling from the 1980s rate so that per capita food output is growing again, helping reduce rural poverty rates in countries enjoying increased agricultural productivity. Finally, the  policymaking and donor communities are now appropriately focusing on how best to stimulate investment incentives, productivity growth, risk management and productive transitions out of agriculture. These broad foci are appropriate and reasonably well-grounded in both theory and empirical evidence.  

BACKGROUND: The recent RV144 clinical trial showed that an ALVAC/AIDSVAX prime-boost  HIV vaccine regimen may confer partial immunity in recipients and reduce transmission by 31%. Trial data suggest that efficacy may initially exceed 70% but decline over the following 3.5 years. Estimating the potential health benefits associated with a one-time vaccination campaign, as well as the projected benefits of repeat booster vaccination, may inform future HIV vaccine research and licensing decisions.

METHODS: We developed a mathematical model to project the future course of the HIV epidemic in the United States under varying HIV vaccine scenarios. The model accounts for disease progression, infection transmission, antiretroviral therapy, and HIV-related morbidity and mortality. We projected HIV prevalence and incidence over time in multiple risk groups, and we estimated quality-adjusted life years (QALYs) and costs over a 10-year time horizon. We used an exponentially declining efficacy curve fit to trial data, and we assumed subsequent vaccine boosters confer similar immunity. Variations in vaccine parameters were examined in sensitivity analysis.

RESULTS: Under existing HIV prevention and treatment efforts, an estimated 590,000 HIV infections occur over 10 years. One-time vaccination achieving 60% coverage of adults could prevent 9.8% of projected new infections over 10 years (and prevent 34% of new infections in the first year) and cost approximately $91,000/QALY gained relative to the status quo, assuming a vaccination price of $500. Targeted vaccination of high-risk groups results in net cost savings for vaccines costing less than $750. One-time vaccination of 60% of all adults coupled with three-year boosters only for men who have sex with men and injection drug users could prevent 21% of infections for $81,000/QALY gained relative to vaccination of high-risk groups only. A program attaining 90% vaccination coverage prevents 15% of new HIV cases over 10 years (and approximately50% of infections in the first year).

CONCLUSIONS: A partially effective HIV vaccine with effectiveness similar to that observed in the RV144 trial would provide large health benefits in the United States and could meet conventionally accepted cost-effectiveness thresholds. Strategies that target high-risk groups are most efficient, but broader strategies provide greater total population health benefit.

Parenteral nutrition (PN), containing fat emulsions derived from soybean, has been implicated in the progression of PN-associated liver disease and cholestasis, particularly in infants with short bowel syndrome. Clinical use of Omegaven, a parenteral fish-oil emulsion, has been shown in recent studies to be a promising therapy to reverse liver disease and cholestasis. This review summarizes the rationale, relevant clinical investigations and future direction of Omegaven therapy for PN-dependent infants.

Obesity – and its related illnesses – endangers the lives of millions across the world. While healthier, more physically active lifestyles can mitigate this, the question remains of how policymakers can get people to switch from being couch potatoes to keen runner beans. This column presents new evidence suggesting that for many even a nudge may suffice.