Make foreign aid great | What it means to take “efficiency” seriously, not as a pretext for destruction

> # Chaos is harmful and stupid

> I think Amtrak is a profoundly dysfunctional and poorly run agency. If I were in charge, I would, in fact, try to pull off some kind of broadly Muskian changes there, including purging large numbers of employees and creating a “fork in the road” mindset. But even so, I couldn’t just “pause” the operation of the trains or shut the agency down indefinitely. Pulling out of ongoing health programs in a chaotic manner is creating huge problems for the global poor and disrupting initiatives that have multiple sources of funding.

> Here’s a particularly horrifying story from Stephanie Nolen about a clinical trial funded by USAID for a new combination contraceptive and HIV prevention device in the form of a silicone ring inserted in the vagina. With the stop-work order, researchers aren’t able to continue monitoring women who have an experimental medical device in their bodies and also can’t remove it:

> > The stop-work order was so immediate and sweeping that the research staff would be violating it if they helped the women remove the rings. But Dr. Leila Mansoor, a scientist with the Centre for the AIDS Programme of Research in South Africa (known as CAPRISA) and an investigator on the trial, decided she and her team would do so anyway. “My first thought when I saw this order was, There are rings in people’s bodies and you cannot leave them,” Dr. Mansoor said. “For me ethics and participants come first. There is a line.”

> Much of what’s been going on reminds me of the line from The Great Gatsby, “They were careless people, Tom and Daisy — they smashed up things and creatures and then retreated back into their money or their vast carelessness.” Musk strikes me as the kind of person who is so focused on his amazing dreams for the long-term future that he simply cannot spare any consideration for actual human beings. We have food shipments stuck on American docks because no thought or planning went into any of this. There’s no excuse for behaving this way.

> # Do more of what aid does best

> I don’t really know the best way to respond to the flood of propaganda coming from the right about all of this. But the best propaganda usually wields elements of truth in service of its aims, and the basic claim that a lot of stuff gets funded that probably shouldn’t seem true. I also think there’s probably nothing you could say to the mass public about this that would be persuasive, because at the end of the day, even the really great aid programs are helping people in other countries rather than Americans, and my sense is most people don’t really approve of that.

> Politics aside, I think two things are clearly true here:

> * The most valuable USAID programs are so valuable that crashing the whole agency is, on net, extremely harmful.

> * The most valuable USAID programs are so valuable that you could dramatically increase efficiency by sunsetting most of what the agency does and plowing all the money saved into its global public health programs.

> And don’t take my word for it: Bill Easterly, probably the most prominent and distinguished critic of western aid programs, says that what Trump is doing is terrible. Because it is terrible! Inflicting harm on some of the poorest and most vulnerable people in the world as a political stunt is a genuinely terrible thing to do. Elon Musk could convince me that he’s making a narrow point about the proper role of the state if he were to throw a billion or ten at GiveWell (he can spare the money), but I’m not holding my breath. Taking the efficiency question seriously and doing more to make sure that scarce aid funds do as much good as possible is really important, and it’s sad that we haven’t seen a serious effort around that.