Tag Archives: Responsibility

A Fat Tax on HIV+

How many others missed this early April news gem?  Arizona Governor Janet Brewer proposed socking obese Arizonans who are enrolled in Medicaid or Medicare with a $50 surcharge unless they adopt a supervised weight-loss program prescribed by their doctor.  (Smokers will get nailed as well.). 

Congratulations to the Gov for the world’s first “Fat tax”.   

The Gov’s arguments run pretty simple along the surface:  unhealthy lifestyle choices and behavior eat up the healthcare budget, so let’s make these miscreants and self-indulgers pay.  After all, why should the public subsidize bad behavior?  Looked at differently:  If some guy like me wants to bicycle the streets of London without a helmet, running the lights, why take money away from cancer research to pay for his brain surgery? (It’s a slippery slope:  skiers and joggers are always breaking ankles, and that costs a lot of money, but taxing them would bring us right back to the obesity risk of blogging from the couch all day.).

If the Arizona governor sounds confused on the workings of blame here, as if people choose to be obese the same way our guy chooses to cycle recklessly, it’s because any debate on the merits or not of the fat tax as a public health policy is misplaced.  This is about trimming budgets, not waistlines.  Ha ha. From a health policy standpoint, blaming the sick sounds perverted, though I guiltily admit somewhat less so in light of estimates that the cost of obesity is the US range from $150 to $270 billion.  Isn’t that more than the continental budget for healthcare in Africa?  Anyway, from a financial standpoint, the fat tax is the sort of decision that will be increasingly more common as politicians and health officials scramble to save cash.

 Now flip to HIV/AIDS.  I recently visited MSF’s HIV/AIDS project based in Khayelitsha township, on the outskirts of Cape Town.  It’s an impressive programme, one that has led to a great deal of innovation on the treatment/delivery side of things and, more importantly, to a sizeable scaling up of HIV+ people receiving anti-retroviral therapy.  Depressingly, I found the decade of advances in HIV treatment have been unmatched by advances in preventing transmission.  It’s simple:  too many men refuse to wear condoms and they certainly aren’t interested in abstinence. 

During my visit I listened as young outreach and community education workers exhorted others on the need to do education in the taxi stands and drinking places, or called for opening hours in the evening, etc. etc.  Essentially, the same hopeful exhortations I heard 10 years ago.  As if a “new” or “improved” community messaging will actually produce a sufficient enough change of behavior to reign in this epidemic.  Aside from the fact that it doesn’t work well enough or fast enough in a context like South Africa, I’m still a fan of this sort of health education.  But limits need to be recognized.  The problem isn’t solvable through education because it’s not caused by ignorance.  That is a topic, though, for a later blog.

For now, back to Arizona.  How long before the logic of the fat tax will be applied to men and prostitutes in South Africa?  There, masses of people knowingly engage in high risk behaviour – becoming infected and (quite different from obesity) infecting others – and then fall ill.  They then assert a right to treatment.  So how long before the “no condom tax” or a “surcharge on unprotected sex”?  How long before money is switched out of HIV treatment into other health priorities at the ministry level, as is already happening on the global stage?  In the end, the Arizona fat tax heralds the coming day when budgetary pressure on the state forces a false distinction between “good” sick people and “bad” sick people.  After the obese, after the smokers, will come the reckless, be it the helmetless riders or rubberless fuckers.

Opening Salvo: Ask the poorest for funding

How does one inaugurate a blog?  If I wait for that deep inspiration, some 3 paragraph reflection that cuts to the bone of the humanitarian aid industry … Well, now you understand why I didn’t get this going last year.  The other strategy is to opt for a more simple debut by just starting.  

Forget DFID (oops: UKaid).  Forget USAID.  Forget even CIDA and SIDA.  Humanitarian aid agencies should start seeking funds from the foreign offices in the countries where they work.  Need money for a cholera treatment centre in Zimbabwe?  Why not ask Botswana, Congo and Ivory Coast for funding?  Need to mount a measles vaccination campaign in Nigeria?  Why not ask the government in Sudan for funding. 

Well, one rather obvious answer would be the unlikelihood of actually getting any money.  And we all know it’s all about the money.   One can only imagine the confused faces of Zambian bureaucrats when a billion per year INGO rep asks for money to run its projects in Bangladesh.   But one other answer, and the answer you’ll likely receive from these governments and INGO HQs themselves, is fundamentally wrong.   The poorest in the world will have turned an important corner when we all get rid of the answer:  “Because we are poor.”

Did anyone notice the news last week that South Africa will launch its own development aid agency?  (See the IRIN article here:   http://www.irinnews.org/report.aspx?ReportID=91651).  South Africa joins emerging powerhouses such as India, China and Brazil as recipients of aid who are now entering the hallowed ranks of the aid business.  Whether a ploy to boost the standing of the country, part of a strategic investment in foreign relations, or, contrary to that rash of cynicism, the governmental embodiment of compassion for those in need, I think it deserves a couple of thumbs up.

In other blogs, I’d like to examine this as part of salutary trend towards ending the Western hegemony of what we refer to as aid.  The Western donor-INGO duet could use a little competition.  But I’d like to focus on something else.  The act of standing up.  In the IRIN article, Ivor Jenkins, of the non-profit Democracy for Africa (IDASA), has this to say about the SA announcement:  “I do think it’s important for us as a country to start to have a sense of responsibility, and giving and not only receiving as we have for many years.’”  

Sense of responsibility.  That just about nails it on the head.  Western aid agencies have been taking increasingly damaging and certainly well-earned straight rights to the chin on their neo-colonial and/or neo-imperial attitude.  {I’ll be writing about that in future blogs).  We swagger through other people’s homelands, delivering the aid to the victims of the state’s own failure towards its people.  States don’t mind the aid, but aren’t quite as keen on the swagger.  Imagine that.  But some governments have had an easy time of playing it both ways, finger-pointing at neo-colonialism while hiding too easily behind neo-colonyism, the international relations equivalent of a Stepin Fetchit routine.  Poor countries as beggars who must shuffle through the corridors of the rich nations, whose economic and historic superiority impose an expectation of  moral duty to ship their money South.

The stereotype creates an existential split.  Not between wealthy countries and poor countries, as if those categories determined who should and should not give aid.  Certainly not between nations actually capable of sending aid to other nations and those incapable (Should Ireland be sending its cash anywhere?).  No, this is a split between those nations assuming the role of beggars or victims and those who assume the position of lord and savior.  More than acknowledging a sense of responsibility, SA’s move is a declaration that poverty is no excuse for the incapacity to help nations, just as wealth is hardly a guarantee for either compassion or generosity.

So future kudos to the first aid agencies that stop reinforcing the existential victimhood of governments in the developing world.  Let’s treat every government as sharing in the responsibility to come to the aid of people in crisis, both within and without their territory.  Let’s stop acting neo-colonial and ask governments to stop acting like neo-colonies. 

And kudos to the government of South Africa for embracing a lesson already being taught by poor people the world over.  If you look closely in places like Haiti, Darfur and Eastern DRC, you’ll find not places where the Western aid enterprise has saved helpless masses of people, but where the WFP convoy-sized gap in aid (2200 kcals per day!) is filled by the countless invisible acts of kindness between families, neighbours and strangers, all part of the same community of the abject poor.