For decades, the U.S. Agency for International Development has sent Americans into the Third World to attack the problems of developing countries: infant mortality and childhood illness, unplanned births and sexually transmitted diseases, poverty and chronic unemployment.
Now AID wants to teach at home what it has learned abroad. In Baltimore and elsewhere, the agency wants to share remedies for the ills of urban America -- infant mortality and childhood illness, unplanned births and sexually transmitted diseases, poverty and chronic unemployment.
Because Mayor Kurt L. Schmoke put aside boosterism and responded to AID's offer with a candid acknowledgment that the city needs help, Baltimore is the first U.S. city to be targeted by AID's "Lessons Without Borders" program.
"It is an unfortunate fact of life that we have in certain parts of our city health problems, housing problems, that resemble those in Third World countries," Mr. Schmoke says. "And, if there are some techniques that AID has used overseas that can be used here, I'd like to apply those problem-solving techniques."
"Lessons Without Borders" will debut today with a conference at Morgan State University that will bring together Baltimore officials and staff members from AID, the major distributor of foreign aid. Vice President Al Gore will be the keynote speaker.
By law, AID is not permitted to fund programs in the United States. But, by offering advice and cheerleading, the agency is seeking to be midwife at the birth of a new generation of U.S. social programs.
AID officials acknowledge that they hope "Lessons Without Borders" will help them sell skeptical American taxpayers on the value of foreign aid. But, budgetary motives aside, American specialists in Third World development say the initiative is a long-overdue recognition that creative programs being used to attack stubborn social problems in Africa, Asia and Latin America could be useful on U.S. soil.
Whether it is immunizations in Haiti -- where in some desperately poor neighborhoods the rate of childhood inoculation is far higher than in Baltimore -- condom distribution in Central Africa or small-enterprise development in Bangladesh, Third World social programs have much to teach U.S. policy makers, say Americans who have worked abroad.
"A lot of us who've worked overseas have been waiting a long time for this to happen," says Julie Convisser, who runs an AIDS-prevention project in Portland, Ore., based on a similar effort in Zaire. "As Americans we sometimes believe no other country has anything to teach us. We're wrong."
Portland's Project Action, the first U.S. effort of Population Services International, which operates in 24 other countries, is among a handful of successful transfers of Third World programs to this country. In Zaire, the battle against AIDS incorporated television soap operas promoting safe sex and condoms on sale for 2 cents apiece in every roadside bar or shop. In Portland,
Project Action has produced MTV-style television shows for adolescents and placed 185 vending machines dispensing condoms at 25 cents each, Ms. Convisser says.
"Lessons Without Borders" was born of a conversation late last year between AID Administrator J. Brian Atwood, 51, who was a few months into his job, and Marian Wright Edelman, the longtime head of the Children's Defense Fund.
As Mr. Atwood described AID's work abroad and Ms. Edelman recounted disheartening statistics on child health and poverty in the United States, they saw an opportunity, Mr. Atwood said last week by telephone from Geneva. He was returning from a tour of African famine areas undertaken at the request of President Clinton.
In a November appearance on C-Span, Mr. Atwood said, he "blurted out" the idea that AID hoped to consult with U.S. cities. Among the viewers was Schmoke aide Lee Tawney. He passed the word on to the mayor, who decided Baltimore should be part of the collaboration.
Mr. Atwood said AID has not previously sought to apply its expertise in the United States partly because the agency long felt beleaguered, a pawn in superpower politics that came under fire for dubious spending.
"During the Cold War, we did waste a lot of money to buy influence overseas," Mr. Atwood said.
The agency's budget peaked in the early 1980s at about $12 billion, much of it directed to fighting communism in Central America and elsewhere. Today, the budget may be less vulnerable to political pressure to steer the aid to allies, but it is down to $7 billion. "Lessons Without Borders" could protect that spending by providing visible evidence to Americans of the effectiveness of programs developed by AID.
Other developments make AID's initiative timely, public health experts say.
The debate over health care reform has given new urgency to cutting medical spending, and one way to do it is to get away from the high-cost approach traditional in this country.
"We Americans like the idea of being rushed to a high-tech hospital," says Dr. William B. Greenough III, professor of medicine and international health at Johns Hopkins. "A great many things can be done at lower cost and with equal efficacy in the community and not in the hospital. In countries with very limited resources, you have to save the patient and save money at the same time."
A striking example is treatment for dehydration caused by diarrhea, says Dr. Greenough, who worked for eight years in Bangladesh before returning to the United States in 1985.
For many years, doctors in Third World countries have treated the condition with "oral rehydration therapy," a packet of a few cents' worth of salts and sugars that can be mixed with water and drunk by the patient. If such a packet is not available, chicken and rice soup is a fine substitute, as Hopkins physicians have long pointed out.
Yet in the United States, severely dehydrated patients generally are hospitalized and hooked up to an intravenous drip at a cost hundreds of times greater than the low-tech alternative. Indeed, because diarrhea is dismissed as a triviality, Dr. Greenough says, it often goes untreated, leading to many unnecessary deaths, particularly among nursing home patients.
Remedies that can be administered at home "lack TV appeal" and are not considered real medicine by Americans, who have an almost superstitious belief in costly machinery. "Basically, our witch doctor's mask is a lot more expensive," says Dr. Greenough, who welcomes AID's push to bring in low-tech methods.
Elizabeth Holt, an assistant professor of international health at Hopkins, is another public health professional who has worked on both sides of the great divide between domestic and international programs: in a poor urban community outside Port au Prince, Haiti, and in Baltimore and elsewhere in Maryland.
In the Haitian community, Dr. Holt says, the rate of complete immunizations by 1 year of age reached 85 percent in the late 1980s. In Baltimore, while nearly every child is immunized by school age, the rate at 2 years of age is only 55 percent, says Dr. Peter Beilenson, Baltimore's health commissioner.
The problem, Dr. Beilenson says, is not a shortage of facilities for immunization and other preventive care. It's the failure of people to take advantage of what's available. That's why Baltimore's Healthy Start program, which seeks to reduce infant mortality and the incidence of low birth-weight babies, hires community residents to do outreach work, identifying pregnant women and bringing them in for early prenatal care.
Healthy Start may have something to teach AID, says Margaret Neuse, deputy director of the agency's office of population. "Lessons Without Borders" should be a two-way street, she says.
In Latin America, Africa and Asia, Ms. Neuse says, she has faced difficulty in getting people to use health services. "I just came back from a place in Ethiopia with a population of 30,000, where a program serves just 10 clients a day. We had a case in Nepal where you couldn't pay women enough to get them to go to a clinic."
Joe Bock, a former Missouri legislator who has worked for two years for Catholic Relief Services, says he sees great potential for transfer of programs outside the area of health care to U.S. soil.
Many programs in the U.S. war on poverty have "failed miserably," says Dr. Bock, who will soon take over Catholic Relief's operations in Pakistan. "We're looking around for new ideas."
One such idea, he says, is what development professionals call microenterprise: tiny, family-based businesses started with minimal capital. The Grameen Bank ("rural bank") of Bangladesh, which has served more than 1 million poor women, has inspired a number of fledgling U.S. programs.
As the United States grapples with welfare reform, microenterprise offers an alternative approach to fighting poverty, one based on poor people becoming small-time entrepreneurs rather than cashing monthly checks.
"Unfortunately, we've had the idea of the U.S. riding in as a knight in shining armor to teach these countries," Dr. Bock says. "In fact, we can learn a lot from what they're doing."