To the Editor:

Susan Raymond's article ("Foreign Assistance in an Aging World," March/April 2003) calls for new priorities in foreign aid based on the growing number of elderly in developing countries and consequently the surge of chronic -- as opposed to catastrophic, communicable -- diseases in the industrializing world. Unfortunately, following Raymond's prescriptions would greatly limit the effectiveness of aid, both on the ground and as perceived by donor states.

First, although the developing world has seen impressive gains in life expectancy and simultaneous declines in birth rates, the vast majority of this "demographic transition" can be attributed to two developing states -- China and India -- with the former receiving almost no U.S. aid. This transition has been much more slowly realized in other developing nations. In fact, the demographic transition and the consequent rise in chronic disease are most evident in those countries that have become most developed; thus Raymond's prescriptions imply a new focus on aid for those countries increasingly able to cope without it.

Indeed, in the vast majority of developing nations -- primarily, albeit not exclusively, in Africa, which is home to the greatest number of un-defined least developed countries (LDCs) -- it is a continued focus on catastrophic ailments that will have the biggest effect. HIV/AIDS, tuberculosis (TB), malaria, and other communicable, catastrophic illnesses disproportionately strike those in the prime of their economic lives and remain the fundamental hurdle to development in nearly all LDCs. Thus, as has already been seen in states such as Uganda, redressing this limitation will have the largest impact on these countries' developmental potential and quality of life.

Second, Raymond's proposals will do little to enhance increasingly stingy foreign aid budgets in donor countries. In democracies, taxpayers demand that aid be manifestly beneficial; Raymond's focus would put the bulk of benefits off by as much as a generation, a difficult "investment" for politicians to sell to voters. Conversely, putting a cap on AIDS or TB would have immediate, tangible effects. Additionally, a focus on chronic disease, instead of communicable, catastrophic ailments, neglects the benefits to the developed world of concentrating on these latter illnesses. Globalization has ensured that communicable diseases know no boundaries, and the rise in same-disease incidence (TB, for example) in developing and developed states shows the dangers to the North of uncontrolled illnesses in the South. Chronic diseases, no matter how prevalent, remain noncontagious.

Moreover, Raymond's prescriptions could not come at a more inopportune time. Developing countries are finally on the agenda of industrialized states. The Monterrey conference on financing development and the formation of the still-undersubscribed Global AIDS, TB, and Malaria Fund indicate both some early successes and some important shortcomings. Thus, following Raymond's proposals risks an even greater political calamity: compelling donors to concentrate on comparatively successful developing countries at the expense of those in greatest need.

Adam M. Smith

Former World Bank staff member