Renowned economist Jeffrey Sachs launched an ambitious — some would say audacious — experiment back in 2005 in his quest to prove that we can end global poverty if we take a holistic, community-led approach to sustainable development.

The Millennium Villages Project targeted more than a dozen sub-Saharan villages and imposed an integrated approach to help these villages achieve the U.N. Millennium Development Goals to address poverty, health, gender equality, and disease.

Funded by World Bank loans, governments, and private contributions, the pilot wanted to see whether conditions would improve dramatically for the half-million residents of the villages in the 10 project sites by improving access to safe drinking water, primary education, basic health care, and other science-based interventions such as better seeds and fertilizer.

The results are in. And boy are they are mixed.

Some harsh critics say the MVP was a waste of hundreds of millions of dollars, the project was riddled with fundamental methodological errors, and there is little scientific evidence that the project attained its goals.

Others, such as Sachs himself in this Lancet Global Health perspective, say that while the outcomes on poverty were mixed and impacts on nutrition and education often inconclusive, “the lessons learned from the MVP are highly pertinent.”

Stanford Health Policy’s Eran Bendavid — asked to contribute a commentary about the endline evaluation of the project published online this month in The Lancet Global Health — falls somewhere between critic and advocate.

"The project, set up as a focused set of interventions implementing an important idea in international development about how to best help the poor, was a terrific opportunity for learning about how to reduce poverty and improve well-being,” Bendavid said.

But the MVP was not set up as a randomized field trial, nor was there any monitoring of what happened in any comparison areas to make sense of what the intervention had achieved.

“No comparison sites were selected either. That was a wasted opportunity,” he said. “The endline evaluation of the project does the best that can be done to eek some information from the limited opportunities for learning.”

Bendavid, an associate professor of medicine and an infectious diseases physician who focuses on global health, said the project invested about $120 per person per year for 50,000 people for 10 years. That’s about $600 million.

“The clearest evidence of benefits from this investment is improved maternal health-care and health outcomes,” he said.

The authors of the final evaluation tried to put a better spin on the net benefits.

“We found that impact estimates for 30 of 40 outcomes were significant and favored the project villages,” wrote the authors of The Millennium Villages Project: a retrospective, observational, endline evaluation.

“In particular, substantial effects were seen in agriculture and health, in which some of the outcomes were roughly one (standard deviation) better in the project villages than in the comparison villages,” they wrote. However, they added, “The project was estimated to have no significant impact on the consumption-based measures of poverty,” and impacts on nutrition and education outcomes were often inconclusive.

But when they averaged outcomes within categories, the authors — of whom Sachs was one — concluded that the project had significant favorable impacts on agriculture, nutrition, education, child health, maternal health, HIV and malaria, and water and sanitation.

In all, a third of the targets of the Millennium Development Goals were met in the project sites.

Bendavid concluded that the endline evaluation “marks an important chapter in our understanding of Africa’s meandering path towards health and economic development.” 

He noted that the project’s evaluation, which was done as well as possible given the difficulties of assessing its impact 10 years on, still failed to shed much light on the MVP’s approach as a method to bring an end to poverty. 

“This was such an important project,” Bendavid said. “We’ll never fully know where it succeeded and where it did not, but this evaluation is a welcome bookend to what we are likely to ever learn from that experience.”

Listen to a podcast with Bendavid.

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The boy’s genetic disorder would have been terminal anywhere, but thanks to Wise and local health promoters, the boy’s family had years with him instead of months.

They found the doctor through the Guatemala Rural Child Health and Nutrition Program, a collaboration between Wise and the health promoters to eliminate death by malnutrition for children under 5.

While Wise spoke to the heartbroken mother, his Stanford research assistant Alejandro Chavez helped the promoters set up inside a local community center to measure the weight and height of local kids to determine their nutrition level.

Chavez and the promoters had worked together for months to create an app for tablets that will make it easier to find malnourished children.

The app they designed will decrease training time for new health promoters and allow the program to expand. The goal is to distribute the app globally to help programs in other countries tackle malnutrition.

Children in crisis

As recently as 2005, about one of every 20 children in this rural area of Guatemala died before their 5th birthday. Almost half the deaths were associated with severe malnutrition.

“The death of any child is always a tragedy, but the death of any child from preventable causes is always unjust,” said Wise, a Stanford Health Policy core faculty member.

Along with other faculty from the Freeman Spogli Institute for International Studies (FSI) and the School of Medicine, Wise created the Children in Crisis Initiative to save the lives of children in areas of poor governance. The program brings together Stanford researchers and students across disciplines.

Nowhere are their efforts better illustrated than in the rural communities around San Lucas Tolimán, in the central mountains of Guatemala.

The program’s effectiveness rests on a deep respect for the local communities merged with innovation by Stanford researchers.

“It’s absolutely essential to any program that the people in need be part of the solution,” said Wise. Unlike many nongovernmental organizations and health programs, Wise believes the way to create a sustainable health system is for the locals to run it, so the health promoters manage the program’s day-to-day activities.

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This leaves the Stanford team free to focus on innovation – such as the new app. They believe the technology could change child health programs around the world. Wise’s team has partnered with Medic Mobile – a nonprofit that creates open-source software for health care workers – which plans to distribute the app to other areas suffering from malnutrition.

The six Android tablets purchased by Children in Crisis are enough to monitor the program’s 1,500 kids through the app.

Role of nutrition

When done well, nutrition surveillance is very effective at decreasing child mortality in poor countries.

“Nutrition contributes enormously to health and well-being,” Wise said as he walked through Tierra Santa, a small community near San Lucas, making house calls. “So the focus of our work turned to improving young child nutrition. It’s not an easy thing to do in a place that’s extremely poor.”

Wise and his colleagues – Stanford medical student Tori Bawel and Stanford professor of pediatrics Lisa Chamberlain – made their rounds during their visit in March. Evidence of poverty was everywhere.

Here, clean tap water is a dream and even the sturdier homes often lack four walls or paned windows, though the children were neatly dressed in T-shirts or colorful traje, traditional Mayan clothing.

It’s hard to provide proper nutrition when most families can’t find enough work to buy adequate food. But a little help can make a big difference.

Bawel, a first-year medical student who plans a career improving health in areas of poverty, was struck by the impact the promoter program has had on the community.

“There are children who need supplements and nutrition to stay alive,” she said. “Without this program, that infrastructure does not exist.”

With FSI’s assistance, the nutrition program distributes Incaparina, a supplement of cornmeal, soy and essential nutrients. The sweet, mealy drink helps the program’s most malnourished children get back on track.

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Every two months, the promoters gather each community’s children to measure their weight and height. Children and their mothers sit patiently, waiting for their turn. The children enjoy a cup of Incaparina, and their mothers eagerly listen to the promoters’ tips for keeping their children healthy.

“It’s very important to me,” said Elsira Rosibel Samayoa, who brought her 2-year-old to be measured. “There are mothers who don’t understand the importance of monitoring their children’s weight, but I do.”

Since its implementation in 2009, the Stanford program has slashed nutrition-based mortality in the participating communities by about 80 percent and decreased severe malnutrition by more than 60 percent – saving hundreds of children’s lives.

However, nutrition surveillance and intervention isn’t easy. Tracking nutrition takes training and expertise, and when the local population rarely exceeds a fourth-grade education, learning these skills is especially challenging. Detailed graphs on a standard growth chart are essential to identifying malnourished children.

“The community health workers are extremely capable and smart, but some have never seen a graph before,” said Wise. “Think about what it is to try to explain a graph to someone for the first time.”

It takes the health workers about three years to learn to graph and then interpret the results for intervention.

Wise said, “So we all got together and said, ‘How do we make this easier to do?’”

The app was the answer.

‘Let’s create an app’

Enter Alejandro Chavez, a recent Stanford computer science graduate and Stanford Health Policy research assistant. He developed the app to collect child health data, then determine the child’s degree of malnutrition and suggest intervention.

“The major goal was to lower training requirements and make programs like this simpler to start and maintain,” said Chavez, who now lives and works in Guatemala, where he gets daily feedback from the health promoters.

“I feel like they’ve been very honest with me about things I need to improve,” he said.

Cesia Lizeth Castro Chutá is a senior coordinator for the program who has worked with Chavez to ensure that the app meets the promoters’ needs.

“The tablet automatically generates the information we need to know,” she said. “It becomes easier to confirm that a child is malnourished and needs supplements.”

Looking forward

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With the app’s launch, it looks like training time for the promoters will be reduced from three years to less than six months. That means new communities can be incorporated into the program quickly, creating broader access to care.

Meanwhile, many health programs around the world are waiting to see how well the Stanford app works in Guatemala.

Josh Nesbit, a Stanford alumnus and Medic Mobile CEO, said, “As more health programs recognize the importance of nutrition and implement community-based interventions, screening and surveillance tools will be critical. We must learn from Dr. Wise’s success.”

Stanford students belong to the first generation that could witness the end of extreme global poverty — in what would be one of humankind's greatest achievements — the head of the World Bank said during a recent talk on campus.

But their generation, he said, is also likely to experience the first global pandemic since the 1918 influenza that killed more than 50 million people.

Jim Yong Kim, president of the World Bank, said innovations in health, education and finance are behind the World Bank's twin goals of ending extreme poverty and boosting shared prosperity for the bottom 40 percent of the global population.

Speaking at the inaugural conference of the Stanford Global Development and Poverty Initiative on Oct. 29, Kim lauded faculty and students for their multidisciplinary approach in tackling poverty and improving public health. He is an infectious disease physician who oversaw World Health Organization initiatives on HIV/AIDS.

"Seeking transformative solutions to challenges of development and poverty that are necessarily cross-disciplinary is exactly what a great university should be doing," Kim said in his speech at Stanford.

The World Bank announced last month that the number of people living on less than $1.90 a day is expected to drop to 9.6 percent of the global population by the end of the year. That is down from 36 percent in 1990.

The bank has pledged to cut that rate to 3 percent by 2030.

"We expect the extreme poverty rate to drop below 10 percent for the first time in human history," he said. "This is the best news in the world today. And this is the first generation in human history that has been able to see that potential outcome." 

Promoting prosperity

One of the co-founders of Partners in Health, Kim was the keynote speaker at the daylong conference, "Shared Prosperity and Health," which drew together Stanford faculty and researchers, plus government and NGO officials from around the world.

Stanford's global development and poverty effort is a university-wide initiative of the Stanford Institute for Innovation in Developing Economies, known as Stanford Seed, and the Freeman Spogli Institute for International Studies. The conference was held at Stanford's Graduate School of Business, which was a partner in the event.

Kim's talk was optimistic about the newly adopted U.N. Sustainable Development Goals, with an ambitious agenda to end poverty and hunger, ensure healthy lives, empower women and girls and attain quality education for all children by 2030.

While those goals seem lofty, Kim pointed to the accomplishment of bringing down extreme poverty to 10 percent, a figure many had once said was impossible.

Ninety-one percent of children in developing countries now attend primary school, up from 83 percent in 2000, he said. And the number of people on antiretroviral drugs for treatment of HIV in sub-Saharan Africa has increased eightfold in the last decade.

"But we're humbled by the challenges ahead," Kim said. "Rising global temperatures will have devastating impacts on poor countries and poor people – and, as we saw with Ebola, major pandemics are likely to disproportionately affect the poor."

Pandemic threats

Kim said that most virologists and infectious disease experts are certain a pandemic will sweep the world in the next 30 years. He said that would lead to more than 30 million deaths and anywhere from 5 to 10 percent of lost GDP.

He blasted the global community for taking eight months to respond to the Ebola crisis in West Africa, noting that Guinea, Sierra Leone and Liberia had among the fastest growing economies in Africa before the outbreak killed more than 11,000 people – most of whom were poor.

In an effort to speed up financial aid the next time such an outbreak occurs, the World Bank is developing the Pandemic Emergency Facility, which would disburse funding immediately to national governments and responding agencies.

Rajiv Shah, the administrator for the U.S. Agency for International Development from 2010-2015, spoke earlier at the conference about his work leading the U.S. efforts to contain Ebola.

"Three small countries with total population of maybe 30 million people had such weak health systems with so little domestic investment – in one country $6 per capita health investment per year – that when Ebola became a crisis there was no first-line of defense," he said.

By October 2014, the U.S. was pouring hundreds of millions of dollars into containment efforts, including the establishment of a 2,500-personnel military deployment to hit Ebola on the ground. Shah said President Obama "stayed extraordinarily true to the science" of containment at the source.

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Stunted children 

Moving beyond containment of epidemics, Kim said the most important investment developing countries could make in their people starts when a woman becomes pregnant. Using a combination of health, nutrition and education will have lifelong benefits for each child, as well as for the country in which each prospers.

The World Bank estimates that 26 percent of all children under age 5 in developing countries are stunted, which means they are malnourished and under-stimulated, risking a loss of cognitive abilities that lasts a lifetime. The number climbs to 36 percent in sub-Saharan Africa, giving those children limited prospects in life."This is a disgrace, a global scandal and, in my view, akin to a medical emergency," Kim said. "Children who are stunted by age 5 will not have an equal opportunity in life. If your brain won't let you learn and adapt in a fast-changing world, you won't prosper and, neither will society. All of us lose."

From 2001 to 2013, the World Bank invested $3.3 billion in early childhood development programs in poor countries. Kim said innovative policymaking and financial tools allowed the bank to help Peru cut its rate of child stunting in half to 14 percent in just eight years.

"Progress is possible – and it can happen quickly. But we must do even more,"he said.

Kim said the world set a target in 2012 to reduce stunting in children by 40 percent. But that would still leave 100 million children malnourished and undereducated. The bank and world leaders should pledge to end stunting for all children by 2030, he said.

"With partners like the Global Development and Poverty Initiative and the entire Stanford community, I'm full of hope that we can indeed be the first generation in human history to end extreme poverty and create a more just and prosperous world for everyone on the planet."

Read more here about another innovation to improve health in the developing world.