Response to Comments on "AIDS, Population, and Policy"--Posner

There were a number of interesting comments. Most focus either on the merits of foreign aid or on the costs of avoiding HIV-AIDS, and I will confine my response to these two issues. 1. I agree that my statement that foreign aid is an inappropriate use of public funds requires qualification in several respects. First, it can be a way of buying allies, and from that standpoint the fact that the money is diverted to the political or economic elite of the recipient country need not be an objection. Second, it can be a way of conferring utility on Americans who have ethnic or religious or family or other ties to people in the recipient countries. Third, it can be a subsidy to U.S. industry if the aid is conditioned on the recipients� using the money to buy U.S. goods; in such a case the net transfer to the recipient nation may be small. Fourth, as in the case of the Indian Ocean tsunami, it can be a form of social insurance. It is also possible that such aid can confer utility on the populations of the donor countries because the plight of the victims of the tsunami triggers altruistic sentiments in those populations, and that emergency assistance, being temporary, is somewhat less likely to be appropriated by the ruling elites of the recipient countries. Perhaps most foreign aid can be assigned to one or more of these four categories, and only the third seems especially questionable from the standpoint of economic welfare. But when people criticize the wealthy nations, especially the United States, for being chintzy when it comes to foreign aid, they usually are not thinking about any of the above categories of foreign aid; rather, they want general wealth transfers to poor countries. And that is what I criticize, since the basic problem of poor countries is not that they are poor, but that they are badly managed; and being badly managed they are unlikely to benefit from handouts. Our present level of foreign aid may be adequate to satisfy the four types of demand for such aid that I have sketched. 2. Several comments raise a good question: if condoms are so cheap, why is HIV-AIDS so prevalent in Africa and certain other poor countries? The answer is that the use of condoms may involve substantial nonpecuniary costs, such as diminution of sexual satisfaction or violation of local mores. Alternatives to condoms, such as abstinence or, more realistically, reduction in the number of sexual partners or abolition of practices such as clitoridectomy and infibulation that increase susceptibility to sexually transmitted diseases, including HIV-AIDS, may also involve heavy �cultural costs.� However, these obstacles cannot be overcome or diminished by the expenditure of substantial monies on buying expensive HIV-AIDS �cocktails� for the affected population. Nor do I agree that because AIDS is at present treatable rather than curable by these �cocktails,� no rational person would increase his exposure to the risk of HIV-AIDS merely because he knew that he could obtain treatment that would prolong his life if he contracted the disease. Given that the full costs, sketched above, of avoiding risky sex may be high, it is plausible that even a slight reduction in the benefits of such avoidance could affect the amount of risky sex. It is true that we spend a lot of public money treating people for diseases that they could have avoided by changing their behavior. These are probably not economically sensible expenditures, because they operate to externalize the costs of risky behavior. Subsidizing AIDS treatments in poor countries invites the same criticism.

Comments

[Kelly Scott]

Re AIDS care and prevention. Provision of AIDS drugs is integrally linked to prevention of its spread. They provide incentive to test AND lower infectivity. Without them, prevention quite literally doesn't work.

Your comment re provision of AIDS drugs increasing sero-incidence is well taken however. And in fact, one could equally apply it to a vaccine. If a vaccine is 25% effective but its existence leads to much greater indcidence of risk behaviors it MIGHT be a net loss as far as prevention.

Then again, this logic applies to ANY prophylactic: the jey is how MUCH more risk behavior stems from provision of care or remedy. Given that a host of factors can change in the equation (e.g. the finding that provision of care actually reduces transmissions), who would deny life saving treatments on the extrapolated logic of changing factors?

In addition, the argument is really no different in kind than saying that AIDS sufferers should be let die, since by so doing one could stem the empidemic thorugh reducing those who can spred it and enhance cost effectiveness thereby. Finally, rarely are such arguments made for all prophylactics, where it is equally true. I mean no personal statement, but somehow one suspects that application of it to AIDS sufferers is as much due to antipathy to people with AIDS or the poor as any heartfelt desire to be pragmatic.

[scott cunningham]

This is a question for a commenter - how does female circumcision increase susceptability to STD infection? I'm assuming the wound heals and scars and therefore there shouldn't be any exposure to blood or fluids that would necessarily increase infection susceptability, right?

[Alone]

Of course, I meant SLEEPING SICKNESS.

[Corey]

"And that is what I criticize, since the basic problem of poor countries is not that they are poor, but that they are badly managed"

That is so typical, it seems like every time the question of money transfers for purely social benefits comes up, the right does the same two things. 1) begin raving about the possibility of bad actors. 2) confuse cause and effect.

The problem with poor countries is that they are poor! They are badly managed because they are poor. They lack the socio-economic resources to collectively restrain tyrants and the education to provide reasonable alternatives to them.

Posner's argument against foreign aid is exactly the same as the "cadilac driving welfare mom" that Reagan repeatedly conjured in the 80s as a reason to cut domestic social programs. It is the same mindset that makes people like him admonish homeless people to "get a job" or say "you would just spend it on beer" rather than giving them a quarter.

The possibility of bad actors appropriating aid is a reason to add safeguards to the aid distribution process... NOT a reason to discontinue aid. At a time when tens of thousands of people in southeast Asia will be soon dying of disease without foreign help, I find it disgusting to stand around worrying about misallocation in a public forum. It can only discourage generosity to see "respected" public figures coming out against foreign aid. (But then again, I suppose in L&E land, generosity has no content)

An interesting question, what would we say is the "basic problem" in the poor country of Iraq, now that we are managing it ourselves?

[Sam]

"How does female circumcision increase susceptability to STD infection?"
My guess is that the scar tissue interferes with natural intercourse and makes exposure to blood more likely. Supposedly sex is more painful after circumcision, which would support this theory.

[Matt]

Sir, you make the apt connection between treating AIDS patients and treating those with other preventable diseases in our own country, but then fail to see the point - we are right then, and you are wrong now.

Unless you believe that there should be no social insurance at all, our society protects the unfortunate at some basic level - small disability pensions from OASDI, Medicaid, food stamps, etc. Do you find yourself qualified to judge which illnesses are the product of poor choices and thus disqualify the sufferer from the safety net? I do not find you so qualified. That is why the services are basic (to avoid too much moral hazard) and universal (to avoid making the decisions you are advocating).

Of course, the practical arguments I should probably make as well are also obvious ones, that a) real economists like your esteemed fellow blogger think treating AIDS is beneficial rather than harmful to developing nations, and b) a significant number of AIDS victims are guilty of no moral misjudgment but rather of bad luck. These include children, rape victims, and the less common transfusion recipients. Judge them if you will

[Anonymous]

Sir.. i'm also ask this question: if condoms are so cheap, why is HIV-AIDS so prevalent in Africa and certain other poor countries? thanks for the answer :)

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