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PaperclipPerfector  3mo ago (text post)   37384 thread views

Culture War Roundup for the week of January 27, 2025

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One of the US Foreign Aid programs that got special attention during the pause was PEPFAR, and I thought the program was interesting enough for a thread top-level comment of its own.

Perhaps others remember this article about it from Asterisk. It's from the "Mistakes" issue, the "mistake" being healthcare economists' prospective criticisms of what was ultimately a very successful program, though I don't think the content of the article justified that framing. The two alleged errors by healthcare economists were premising their cost-benefit analysis on a fixed foreign aid budget, rather than PEPFAR's budget being a new appropriation, and failing to forecast the drop in cost of anti-retroviral therapy; unfortunately, the article doesn't explain what caused the drop in price.

Effective Altruist Amos Wollen published a defense of PEPFAR on the 29th, which doesn't steelman the programs' current critics, but does address the current politics of the programs.

Wollen relies in part on this Center for Global Development blog post, by the same author as the Asterisk article (with very similar content), which claims that demand from PEPFAR for generic ART medication was itself what reduced the cost, but I really want to see proof of this.

Sidenote: The healthcare economist that the Asterisk/CGD contributor use as an example was Emily Oster, who might be familiar to some of you.

Effective Altruist Amos Wollen published a defense of PEPFAR on the 29th, which doesn't steelman the programs' current critics, but does address the current politics of the programs.

Man, that's pretty charitable to just say it "doesn't steelman". To wit:

In response to a tweet by right-wing PEPFAR advocate Richard Hanania, many of his followers expressed their grievance at the country with the largest share of the world’s GDP shelling out a small sliver in foreign aid to do something unambiguously good:

As for whether the US has reason to set aside a skimpy sliver of its budget for a programme that has saved easily more than 20x the lives that the Iraq War stole, the most important justification for PEPFAR funding is that saving that many lives is straightforwardly morally good, and failing to engage in a baseline, easily-affordable level of Christian charity when that many lives are at stake is Satanic.

OK, well, I'm not Christian, so that line of defense isn't really going to work for me. More importantly though, this doesn't actually meet the argument head on, it just insists that you have to agree that it's morally good because it's such an eensy-weensy-teeny-tiny expense that does so much good. Without arguing about just how eensy-weensy the program is or how much good it does, this prompts a couple immediate thoughts:

  • If it's so tiny, why is it critical for American taxpayers to cover it? Things that are so tiny and so good should be pretty easy to convince people to participate in voluntarily rather than via confiscation.

  • In the event that there's really a coordination problem, that it can't be done via charity for some unclear reason, why isn't it an internationally shared expense? It's super-duper tiny, barely costs anything at all, and does so much good, so it should pretty easy to get the UN to fund this instead of it just being a responsibility for the United States.

  • This argument is fully general for anything that you just think is good in the federal budget. It precludes ever cutting anything if its advocates say that it's really important and doesn't cost that much anyway. If it's true that nothing that supporters think is good and costs less than eleventy bajillion dollars can ever be cut, fine, I'm probably just going to oppose more or less all new programs since they can apparently never be ended or shifted to the private sector.

At the end of the day, my real question is why the hell HIV spreads so well in Africa. I've read the explanations and they just don't really make much sense to me. In the United States, Europe, and Asia, HIV just spreads really poorly among heterosexual populations that don't use intravenous drugs.

People have mentioned extremely high rates of promiscuity in Africa - cheating, prostitution, men with multiple families, etc. - and dry sex, which is overrated because of its surprising nature. The main reason for high heterosexual HIV transmission rates is both more pedestrian and more unpleasant. Few African women, particularly in urban slums and to some extent in rural areas, have access to appropriate feminine hygiene stuff (period products, vaginal healthcare, etc.), and as a result many develop long-running vaginal infections, UTIs, or other issues. Because HIV is blood-borne, women with infections or open wounds in their vagina are much more likely to pick it up from sex, and similarly for men having sex with HIV-positive women and contacting their blood. Unfortunately, this is a more difficult problem to solve than anti-retrovirals, and I don't really foresee a similar program to PEPFAR creating much improvement in that respect.

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