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Scott-featured global health philanthropist and activist John Green made a video about TB treatment and USAID. tl;dw, TB is the brick-shithouse of bacteria, so treatment takes 4-6 months, but the good news is that people mostly aren't contagious during treatment. Stopping treatment increases the risk of treatment-resistance, including the spread of newly-treatment-resistant strains, so interruptions in the supply chain are a major global health problem. Yes, it's bad that global health was overly reliant on the USA, but it requires government-level funding and logistics. (Unsaid, his family pledged $1m/year 2024-2027 for a USAID TB program in the Philippines, in addition to $6.5m for Partners in Health, so he's literally put his money where his mouth is.) His contacts in confirm that drug supplies are being interrupted.
Even if one wants to cut USAID, a stop-work order, rather than a phase-out, was likely a net-negative by most measures of utility.
How many people are affected by this order versus the number of noncompliant patients who get their jar of pills and just never show up again or just forget to take the pills?
A quick nih search gives me:
So maybe the US money helicopter stopping for a few days doesn't matter as much as you're making it out to be. And maybe the Philippines can scrape together enough money to buy the pills themselves, and maybe do all the other supporting activities a bit more efficiently.
The libs keep saying that foreign aid is only 1.2% of Federal spending. Well the TB aid is only 1% of the Philippines national budget so maybe they can afford to pay for it themselves. Don't forget that the US helicopter money is also redirected to promote equity and inclusion, spend on sinecures for connected people, and otherwise wasted.
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Seventy years pro-life activists have called their opponents baby-killers and it did not swerve their opposition's resolve by one inch.
Conservatives, particularly MAGA conservatives, must harden their hearts as such. In the coming months and years, there will be no end to the wailing. They will beg you in the name that all that is decent and humane to give them the one exception and save many lives. The rationalist crowd will come to you with spreadsheets and lives per dollar and give logical arguments to save lives. You will be constantly bombarded with propaganda designed to psyop you to support the return of the old status quo.
Put on your biggest smile and say no. That's your cross to bear. Resist the temptation to give in, and to be seen as 'one of the good ones'. Mercy and compassion are the luxuries of the victor, and you have not won yet. This is but the first of many battles in a long war. If your opponents say that your proposals will cost millions of lives, say to them: "Billions." And do what you intended to do, and do it so throughly and completely that it does not have to be done again. Embrace the virtue of Lycurgus and destroy what you must to save what you can.
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This is a hostage puppy, which has been discussed here before.
It's not a hostage puppy, it's collateral damage. There's no evidence that USAID was shut down and the bureaucrats decided to stop TB treatment first. Everything got axed, the good with the bad.
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The reason this is being done so crudely is because every less-crude attempt made in the past was stopped. If you let them slow you down they'll keep finding reasons to do it until the whole thing grinds to a halt.
There was a limited supply of veto power and it has been squandered on less important issues. Don't blame the bartender for cutting you off, blame yourself for drinking too much.
My thoughts throughout this Presidency (all three weeks of it) has been a mix of:
Damn, Trump is reckless, unprofessional, and vain.
How the fuck does he have so much ammo?
There's a plane crash? Air Traffic Controllers were hired under a racist system. Foreign aid? Transgender operas in Colombia. Funding basic science? >60% "administrative overhead" tacked on. Threaten Canada with tariffs? Suddenly our border security is a valid issue. Random whatever? $20M in subscriptions to the Associated Press, and another $1.6M to the NYT.
It feels like a weird mirror to the Texas Sharpshooter fallacy: He gives every indication of shooting blindly, but there has actually been a bullseye where he hits all along. That could be luck or good spin, but the most compelling story is that everywhere is that bad.
(Related joke: There has been a shooting at a peaceful protest! A child molester, a sexual assaulter, and a convicted felon illegally carrying a gun are the only people injured.)
I still don't think he's doing a good job, but damn does he have a strong narrative.
Corporate security at my job keeps referencing "attack surface". How much vulnerable and hypothetically open to malicious action "surface" are we exposing to the world? They go a bit far in fearing this, in my opinion. Saying we shouldn't be handing out business cards on foreign trips, etc. But their larger point is valid. If you go around leaving possible vulnerabilities exposed to the world, then someone is going to exploit some of them.
Millions spent on transgender animal research, millions on Central American gender assessment clinics, etc, etc. They are hanging targets for a Republican Texas sharpshooter to accidentally hit while making broad cuts. The attack surface was massive so even blundering unfocused "attacks" happen to stike it again and again.
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The name of the concept you're reaching for is "target-rich environment".
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I've been digging into some of these laws and regulations. I'm coming away more convinced than ever that democratic governance is a myth. No regular person could possibly comprehend the byzantine labyrinth of rules, regulations, and case law required to competently evaluate government decision making.
Every spigot of federal funds grows into a hydrothermal vent of highly-specialized fauna perfectly adapted for siphoning-off those sweet sweet grants. Congress can't fix the problem, because all they are able or willing to do is appropriate more funding for things.
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Can you give examples of past attempts? As a cynic, it wouldn't surprise me, but this is The Motte, not The Bailey, so I don't want to assume that what wouldn't surprise cynical, old me is correct.
Afghanistan and Syria withdrawals last Trump term come to mind. Generals bragged about playing shell games in Syria with troop numbers.
https://nypost.com/2020/11/13/diplomat-says-officials-misled-trump-on-troop-count-in-syria/
Different branch of gov, but basically the same idea. Leave wiggle room and you leave them room for to wiggle out of the order.
Relatedly, pulling out of Afghanistan. We finally did it, but the military leadership insisted on dragging their feet and doing it in an incompetent fashion to undermine Biden and it worked.
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Reagan is the classic example. But pat Buchanan in the 90s is an additional attempt. Government grew over the time period.
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The problem, for me, is that my options are not between an orderly phase-out and a stop-work order, but between a stop-work order and the status quo. I firmly believe that doing this in a slow, orderly fashion would just result in caterwauling about how we're killing the children in the future and that this caterwauling would continue apace through the next administration, which would restore funding in full plus a little extra bump for their trouble. If, like me, you want many of these activities curtailed, you just have to bite the bullet and accept that it's going to be an ugly process where every single person denied a previously received bit of American largesse informs you that you're literally killing children.
So, the solution, for me, is to say that the mistake is not in stopping now, but that we ever began the process of giving away so much American money that can never be redacted in the slightest and that is never enough to even begin to slake the demand.
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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.
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.
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.
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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 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 an 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.
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.
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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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People dying of TB is bad. But it's net negative only for the countries with the TB problem. Why should US subsidize this?
You know how every time there's a new potential pandemic you hear about how new diseases are deadlier because the pathogen is not adapted to human hosts? And how a well adapted pathogen doesn't want to kill the host, it wants to live in the host long enough to propagate to other hosts?
TB is arguably the most human adapted pathogen out there. It has our immune system beat six ways from Sunday, kills slowly over an extended period of time, and can lie dormant for years before becoming active again (which means healthy people you let through customs may have a passive infection, and will only turn active and contagious later when they're already in the country). It is also arguably the most difficult bacterial infection to cure. You need to be on multiple powerful medications with significant side effects (including potential blindness) for 6-9 months in order to cure it.
If a TB strain managed to become resistant to one of those medications then it may not be possible to cure it, not without new drug development. In the US we've managed to mostly extirpate the disease at great cost over many years of effort. If an antibiotic resistant strain showed up it could undo decades of progress in US health.
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It'd be interesting to compare the cost-effectiveness of USAID's reduction in pathogens brought to the US and quarantining all international travelers and cargo ships, including economic impact, but the counterfactual in the comment you replied to was "phase-out," not indefinite continuation.
Ah, thank you for pointing this out. It's already paid for and thus unnecessarily cruel - this is the main point. IMO good faith interpretation, from the US government perspective the management of the drug supply chain isn't free, so they are just saving on that.
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Because while the NGO's left hand is open demanding money, the NGO's right hand has boatload after boatload of diseased "asylum seekers" poised on your border. One way or another, they will make it your problem.
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The selfish motivation is that pathogens don't respect borders. Travel between the US and the Philippines is relatively common, almost a million Americans visited the country in 2024. Any one of them can pick up a new antibiotic resistant strain of TB and bring it home, at which point it's our problem. Solve the problems where they are so we don't have to solve them here in the future.
Wouldn't it be cheaper to:
After a while these poor countries find new sponsors who will solve their problems. Or solve it by themselves.
Poor countries find new sponsors, like China or Russia
Poor countries start advocating for China and Russia and against the US on the world stage
Europeans, who think of poor countries as intrinsically virtuous, pick up the tune
Europeans become more anti-American and wrestle their governments into reducing support for US plans and military logistics
Core US interests abroad, such as supporting Israel, suffer or become significantly more expensive
More money winds up being spent on workarounds than it would have cost to continue bribing the poor countries
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Banning all travel to and from places millions of Americans visit each year would be costly to the economy so while it might be cheaper for the government it would surely be more expensive for the country. Also, I want freedom to travel where I please. We shouldn't impose travel bans that aren't actually necessary.
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