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John Green is a good point of discussion in philanthropy apropos USAID. The mediocre king of YA and man who appears truly convicted in his beliefs has, in addition to his tuberculosis charity, also contributed in fighting maternal mortality in Sierra Leone. He uses some of his money to, he believes, improve the world.
Does he? Are we a net positive when we spend money on maternal mortality and tuberculosis in the third world?
You ask John and the NGOs involved in these efforts what the causes are and they'll rifle off a list of things money fixes. For Sierra Leone, if they had better infrastructure, more hospitals, more trained medical workers, antenatal care and all the supplements in the world, their rates would fall. For tuberculosis, the relevant parts of the above and also staff ensuring patients complete their regimens. Americans regularly fail to complete antibiotic regimens, what of those in far poorer, far less equipped nations? Their failures are prolific. They use the wrong medications, or the right ones at the wrong amounts, and either way the patients at unacceptable frequency fail to complete their regimens.
Add to this pharmaceuticals in countries like India pumping out genericized versions of American pharmaceutical products under government license and we reach the outcome of multidrug-resistant tuberculosis.
And all this happened under robust US aid spending. More money in a year than John Green, who does well for himself, will make in his lifetime and beyond with the royalties of his estate. We can no longer afford to tolerate these practices. The solution is not more money, we've tried that, it's not infrastructure, health workers, medication access. The solution is those countries cease public treatment of tuberculosis, it is travel bans, and it is drone strikes on factories making knockoffs.
This is where John Green, Scott and EA utterly fail. It's true that with first-class western medicine far fewer mothers in Sierra Leone would die, but the root cause is population health, it's the genetic basis for particular risk and susceptibility to postpartum hemorrhaging. Throwing money at Sierra Leone will not solve that population health issue, it will also not improve its socioeconomic conditions. Nigeria is far wealthier, similar rates. Liberia at least for a time, far lower rates. Haiti, same as Liberia. When those mothers live through one birth, what happens? More children, more daughters, more future mothers, more future aid necessitated. But at least with Sierra Leone and broadly with efforts to lower maternal mortality you can't say an obvious externality is superbugs. With tuberculosis we know outright the process is creating superbugs and the response somehow has been "give even more money."
No, it is no longer time for that. If India cannot manage its tuberculosis issue for itself, if India has to keep on stealing American weapons against illness only for their population to dull them flat through misuse, they don't get help anymore, they don't get to make our drugs anymore. They must live or die on their own mettle, because they aren't playing a domestic game with domestic consequences, they're toying with a pandemic. Every dollar spent "fighting" TB in the third world is a dollar spent adding fuel to the fire of a real global health crisis. I can't blame John, he's so charmingly naive that he's constitutionally incapable of considering the solution is doing nothing at all. I can blame Scott, he knows better.
Directionally I agree with EA and with the moral judgment of value in eradicating disease. I believe it in completely, but lifetime treatments, fighting and suppressing and temporary cures, these do not constitute eradication. When we can engineer treatments that do eradicate, when we can target population health through genetic engineering, such as in reducing the risk of postpartum hemorrhaging, when we have the panacea that can wipe out AIDS and TB and whatever else, it won't be merely worthwhile but our true moral obligation to see it through the world over.
But efforts that increase suffering -- like increasing populations by creating more mothers at risk in Sierra Leone, creating more people throughout sub-Saharan Africa who will ultimately become infected with HIV in excess of those spared of mother-to-child transmission, and separately causing the emergence of multidrug-resistant tuberculosis, these are not actual charity and they are not love. Blindness to the consequences of your actions from whatever flavor of naivety is not love, knowing what is truly best for someone and acting in accordance with that is love. Love would be making treatments in Sierra Leone dependent on subsequent sterilization, same for PEPFAR. Love in India would be establishing secure facilities where under no circumstances are patients permitted to leave during their entire course of their regimen. Call it Directly Observed Treatment, Until Cured. It may sound cruel, but our current "kindness" is leading many of these countries straight to hell.
Hold up. India is catching strays here for no good reason.
We have DOTs programs. They're paid for domestically, and while I'm sure donations are accepted, the largest source of foreign aid I could see is a $400m loan from the World Bank. I believe USAID has spent about $140M since 1998.
TB treatment is a national priority, and immense amounts of effort are put into DOTs, surveillance and follow-up.
India has a compulsory licensing scheme for life-saving drugs, which you're free to disagree with (good luck coercing a nuclear power or directly attacking it). It sells generics for about 10% of the retail price in the States.
I did some napkin maths:
The Indian state saves about $1 billion through CL a year, so about 5 billion USD by 2030. The US would lose a maximum of around 3 billion a year on pharma revenue, but that's with the unrealistic assumption that there wouldn't be any cost-negotiation or the availability of generics.
The CDC shows that TB treatments in the US can cost tens of thousands for normal TB, 150k for MDR and >500k or more for XDR.
You guys have around an order of ~100 MDR cases a year already. That is despite screening for immigrants and travelers being put in place.
If India paid standard prices, they're looking at about $100 billion for the same level of care. This would be untenable in practice, and TB incidence would soar. This would have knock-on effects, both globally, and in the States, existing screening is already rigorous, so God knows how much you'd end up paying when more MDR and XDR TB cases pop up. I'm not qualified to put firm numbers on the expense, but it ranges from anywhere between 10 million USD to 1 billion USD a year in treatment costs.
You'd be looking at quite serious economic fallout from sanctions, and the theoretical gains of about $2B USD PA are unlikely to manifest, since if India somehow was forced to stop using generics, they'd likely just spend less and then face an explosion in TB cases that wouldn't particularly respect borders. If the US really put the squeeze on, then India could well retaliate by flooding international markets with generics for other drugs.
And of course, do you really want to piss of another >billion strong nuclear power which is a willing partner against China? From a pragmatic point of view, I'd wager not.
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Uh, what does India stealing medical patents have to do with anything? Are their knockoffs less effective? Pardon my ignorance, but it would seem that a stolen antibiotic is, in terms of effects, identical to a purchased one.
While the factories likely have purity issues, the main issue is the antibiotics are culturally ineffective. That is, people routinely do not complete their regimens, which is a primary driver of antibiotic resistance. There are subpopulations in America where this is also true, but it is believed to be a widespread problem in India.
How would making India buy antibiotics from the US do anything about this?
The implication is that they are not allowed to have them except under conditions strictly administrated by American doctors, probably few at all.
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It is not clear that finishing the course prevents resistance.
I was going to post this, and it seems correct for antibiotics in general, but it may not be true for TB, due to the nature of the illness and the fact that it takes megadosing on antibiotics for months to make a dent in the infection.
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No, opposite problem. They are effective, they aren't utilized properly. Prescribed wrong, treatment regimens not followed, both kinds of failure cause TB to gain further drug resistance.
Again, has nothing to do with who makes the antibiotics.
Whether it's made locally or shipped to such nations the solution remains prohibiting methods of treatment that risk further drug resistance, e.g., changing to requiring the locking down of patients for the entire duration of treatment.
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Not OP, but if we were giving them antibiotics we might at least hope to suggest they use them responsibly. If they just steal them instead, they can hand them out like candy.
(Again, not OP, and I have no stake in this issue, just suggesting a possible connection).
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The point he's making is "if Indians misuse antibiotics then they shouldn't be allowed to have the ones we're trying to keep in reserve; since they'd respond to a refusal to licence by seizing the patents, blow up the physical factories".
Sure, but, India is not asking permission. They get ahold of a new American made drug and cheaply copy it. Once you already know the molecule, making copies is easy. It is discovering and testing potential drugs that is enormously expensive. Europe and India leave that Herculean task to America.
This is not responsive to @jake's suggestion. He was suggesting that the West respond to Indian misuse (e.g. feeding to animals, or rampant failure to finish courses) of in-reserve pharmaceuticals (i.e. those we're trying to keep microbes from becoming resistant to) by not only revoking their patent licences and embargoing India, but literally blowing up Indian generic factories producing these drugs with airstrikes.
I reiterate that this is Jake's suggestion, and not mine; while his suggestion avoids your objection, there are others it does not avoid, such as "acts of war against a nuclear triad power are a bad idea".
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If the United States tells the people of the Global South "We have the ability to save you from a painful death, but we are choosing not to For The Greater Good", the survivors will be fertile soil for Usama bin-Ladin 2.0 or some other radical cultists. They will be much more sympathetic to the Peking Clique, if and when they decide to demand something Washington is unwilling to concede. No fortress you can build will be strong enough to keep them out, when, like Belshazzar, you are numbered, weighed, and divided.
The cost of indefinitely providing medical care to people who cannot care for themselves may seem steep, but it is trivial compared to the cost of not doing so.
The US budget and financial system is extremely overburdened and the nation has a vast amount of debt, to the point that the costs of servicing it are an increasingly significant cost in the budget. Your options are to rip the bandaid off now, or to let things get worse by subsidizing the creation of more aid consumers until the US actually does collapse (or the populace gets desperate enough to elect a strongman) and there's no aid to anyone anywhere.
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That's fine, as long as we don't have our very own glowies issuing passports/visas to known fighters so they can come train how to fly airplanes in the US. And also if we don't import half-their country to a single US state, we'll be fine.
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You are making the classic mistake of presenting the status quo as the undesirable alternative to the status quo.
Notably, bin Ladin did come from the Global South, which was/is already fertile soil for various radical cultists, however you decide to define the term. Moreover, this occurs despite the status quo already being the funding line, as opposed to the supposed consequence of not funding.
The mistake in the framing is presenting the lack of preferred policy as a difference in nature, as opposed to a difference of degrees. This creates a discrediting effect- 'why should we keep paying for the thing we'll get regardless of if we pay'- rather than a cautionary effect 'things will be worse if we don't pay.'
The issue/weakness of the later, of course, is that an argument of efficacy has to prove it's efficacy, and that has the burden of being coupled with what's being paid for in practice and not just in objective. Like, 'USAID is spending money on life-saving things... but does so by also paying for gay operas.'
You can like opera. You can approve of gay operas even. But a medical cause that is spending on gay operas is not a compelling medical cause, even if people would be- in theory- willing to support medical causes.
(This is a classic weakness of government agencies that lose their sense of purpose / mission and get scope-creeped into fields outside their focus. The consequence of losing public legitimacy and political support isn't losing the scope-creept stuff, but also the efforts that were the nominal original focus.)
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The US would never implement such a policy, not without an effective or actual revolution in governance. The brutal pragmatism wouldn't stop at "Good luck with that," it would be a fully isolationist US or West. We're talking a mined, milecastled and turreted border wall with Mexico with no entrances, boats flying unacceptable or no flags being sunk, no flights to those countries, no business in those countries, no telecommunications access permitted from those countries. We're talking skin color as a reason for detainment and summary deportation. It's a nightmare scenario.
The position was hyperbole in service of my conclusion: we do have an ultimate obligation to help these countries but what we're doing right now is hurting them. Hurting them so much threatening them with drone strikes would be superior than our "aid." It's not charity to think of every human as a blank slate, it's confusing what ought to be for what is, and profound differences in human behavior is what is. Just health differences, that our discourse has devolved so far that in another environment I might have to heavily couch myself to avoid the impression of wrongthink when all I'm wondering about is a genetic propensity to PPH, this isn't right, good, truthful. Now instead we're in decades of a geopolitical implementation of the trope of the pageant girl's vapid "I'm going to work for world peace." Charity must be tailored to the target, it must be undertaken with knowledge of the recipient's strengths and shortcomings, all of them. In other words, it must be undertaken out of actual love. John Green wants to show love, he grew up Christian in whatever surely protestant environment that didn't teach it right, though anymore, what churches do? But when he donates to fighting maternal mortality he isn't thinking as hard as he needs to be, he isn't asking, okay, well, what if this just means a lot more girls will be born who wouldn't be, what if they grow up and they need all this, and what if the money isn't there, and they die? The most important questions with these kinds of charitable projects must be above all others "What is our plan for obsolescence?" — "What is our plan if we have to stop?"
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One of the arguments in the post you are replying to would require tens of thousands of 9/11s to get close to rebutting .There are already billions of wannabe Bin Laden's in the global south, most currently don't have the resources or skills. If anything, propping them up makes the terrorism and future war problem worse...
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Radical Islam is already running wild in Africa and getting worse by the day, partly because of how ineffective US military aid is. African countries have already been turning away from the United States by the dozen because of the US’s inability to help them fight it. America’s help is weak and ineffective partially because the aid is conditioned on a bunch of stupid aesthetic requirements like “respecting bizarre western sexual practices” and “not being a military dictatorship”. The Russians and the Chinese don’t make these totalizing demands. They are more than happy to trade guns and effective military advisors for mineral rights on a transactional basis. The Africans like that better because relationships with Russia and China, while mercenary, actually allow the Africans to govern their own countries and don’t turn into a clingy codependency where they have to live and rule according to what makes American liberals feel good.
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To be crude: Those folks will become fertile soil for MOAB 2.0. Like the people unlucky enough to have shared a slice of continent with Osama bin Laden.
My gut tells me this isn't true at all. Where is the direct negative for the western world to not giving free stuff to an infinitely growing third world?
It feels like you are hoisting the western world on its own petard. Leveraging the massive amount of sympathy and charity it has given, which has driven it to its knees, in order to justify it continuing the practice to not face the wrath of the people it has been saving for the past century.
"Better keep giving charity to us or we will kill you."
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Whenever I hear an argument along the lines of "We have to engage in leftist policy X, or else terrible thing Y that right-wingers fear will happen!", I reach for my tired disappointment.
Be honest with me now: you don't want to provide aid to the people of the Global South to prevent radical cultists; you want to provide aid to the people of the Global South because you think it's the right thing to do, and Osama 2.0 is a convenient argument you came up with.
I do favour providing aid to the Global South because I believe that it is the right thing to do, and wish everyone else supported it for the same reason.
However, as many people here do not share that moral instinct, I am left only to appeal to their self-interest.
The fact that they point in the same direction is not a coincidence but the working of karma. If you harden your hearts towards the suffering of the least fortunate among you, it will come back to bite you in the rear end.
The trans-Sarahan slave trade was at least as large as the trans-Atlantic, but one observes that there's no class of descendants begging for reparations in the Middle East. In large part because they castrated male slaves to prevent that issue.
Hardening your heart does not tend to bite you, if you harden it enough. Being charitable is good, being hard-hearted is advantageous, it is the mushy middle that bites you. History makes many arguments that moral improvement comes with surprisingly high and enduring costs. Europe is steadily learning that lesson.
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Do you prioritize defending against the future foreign enemy, or the current domestic one?
If we prioritize defeating the domestic one, we will at least have the resources and the willing soldiers (and industry to support those soldiers) to defeat the foreign one if and when he appears.
The reverse is not as true; if we refuse to defeat the domestic one we will not have the resources or the personnel to defeat the foreigners we simply prioritized less.
Also,
The NGOs are more than capable of funding these operations on their own (perhaps with fewer administrative staff if they want the altruism to actually be effective). The fact they will not suggests they just want it done with the tax dollars- and if they wanted it done with the tax dollars they should have adjusted how much of a domestic enemy they wanted to be (which they didn't).
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The fact that they point in the same direction like this is a sign of motivated reasoning. Karma is not real.
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But from what I hear USAID has been making the Global South more sympathetic to the Peking Clique, as you call them, by showing up and demanding to know how the sexual minorities are being treated. Eliminating USAID is not a commitment to forever forsaking the Global South and banning all foreign aid forever, it's shutting down an organization that's served as an arm of US coercive diplomacy.
And, from what I hear, an arm which didn’t coordinate with the state department.
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Do you have evidence of USAID unjustifiably deviating from best practice or Sierra Leonians having a genetic susceptibility for postpartum hemorrhaging?
Postpartum Hemorrhaging as leading cause of maternal deaths in Sierra Leone.
Particular disposition to hemorrhaging is my speculation, but when Sierra Leone at least was the world capital of obstetric mortality with >1000/100K while Haiti had <500/100K, a genetic basis is the rational guess.
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