Successes of international aid and effective development charities: global health

Does aid work? Some authors argue yes, and we should give more. Others argue that it has been ineffective, or even hindered development of poor countries. It’s clear that some charities are much more effective than others, and certain forms of government-financed aid can sometimes exacerbate corruption within a country. But there are also examples where aid seems to have been rather effective, particularly in the area of health. Here are some of its successes, along with some recommended charities to donate to if you want to contribute to ongoing achievements.

1. The Marshall Plan. 

No, this wasn’t a health-based aid project, and in terms of effectiveness this is probably the least empirically justified out of the whole list.  I provide it first because many opponents of aid in the UK seem to have forgotten how the UK and Europe as a whole were recipients of large amounts of aid not too long ago. After World War II, European countries benefitted from a substantial financial gift from the United States in order to rebuild their devastated infrastructure.

In today’s currency, a Marshall Plan would be worth more than $740bn.

2. Eradication of small pox.

Small pox used to kill millions of people every year. In the 1960s a plan was announced to provide sufficient vaccinations to completely eliminate the virus within a decade. It was successful; the last case of smallpox was in 1977. About a third of the funding was provided by ‘international assistance’.

3. Near-eradication of polio. 

Infection by poliovirus lead to the paralysis of tens of thousands of people each year in the early-mid 20th century.  In 1988 the World Health Organisation (WHO) resolved to eradicate polio worldwide. That year, there were an estimated 350,000 cases globally. By 2012 this had fallen to just a few hundred cases. The WHO is funded by governments of the United Nations. Members of the organisation Rotary International have also raised and donated huge sums (over $1bn) to help fund provision of the polio vaccine.

4. Near-eradication of Guinea-Worm disease.

Guinea-worm disease is caused by a parasitic worm caught by drinking contaminated water. Symptoms include “intense pain…fever, nausea, and vomiting. 

Unlike polio and smallpox, there is no vaccine. But the Carter Center, an NGO established by former US President Jimmy Carter, has helped almost completely eradicate it, working alongside the WHO, UNICEF and other groups to prevent contamination and infection:

“In 1986, the disease afflicted an estimated 3.5 million people a year in 21 countries in Africa and Asia. Today, thanks to the work of The Carter Center and its partners — including the countries themselves — the incidence of Guinea worm has been reduced by more than 99 percent….In 2012, there were 542 cases reported in South Sudan, Mali, Ethiopia, and Chad.”

5. Big decline in deaths and suffering from malaria.

Malaria causes illness in hundreds of millions of people each year, and kills thousands (mostly children) every day. But since 2000, these numbers have fallen by 25% globally, and 33% in Sub-Saharan Africa. Much of this is because of the mass-distribution and use of insecticide-treated bednets, which charity-evaluator GiveWell describe as ‘among the most cost-effective ways to save lives‘. These bednets have primarily been funded by the governments of wealthy nations via The Global Fund. The UK’s Department for International Development, for example, has funded tens of millions of nets.

-The Against Malaria Foundation. Private donations have also helped buy bednets. Bill Gates is a notable contributor to the Global Fund. For those of us who aren’t billionaires, the Against Malaria Foundation is a highly recommended charity that spends all of its donations on bednets. So far, over 475,000 people have donated more than $18m to buy more than 5 million nets, showing that everyone can make an important contribution. The Life You Can Save, GiveWell and Giving What We Can currently rate the AMF as the top charity to support for private donors; this means their work has demonstrated very high cost-effectiveness and high transparency/accountability. You can donate to them here.

6. Near-eradication of River Blindness (onchocerciasis) in West Africa. 

The OCP, a 30-year program lead by WHO and United Nations Development Program, ended in 2002 “after virtually stopping the transmission of the disease in the 11 West African countries covered by the program. This “reopened to farming 60 million acres of land once abandoned to the disease, and protected the sight of an estimated 30 million people at risk for blindness”.

A new program, the APOC, is now seeking to control and then eliminate it from the remaining endemic Africa countries over the next 2 decades. It is funded by a number of countries, including the UK and USA.

7.  Measles vaccination success

In 2011 around 158 000 people, many children, died of measles. But the World Health Organisation reports that, because of vaccination, there has been a 71% global decline of measles since 2000. This vaccination campaign has been supported by the WHO, UNICEF, the American Red Cross, and the United States Centers for Disease Control and Prevention.

Other vaccination campaigns include:

8. Hepatitis B

In China, hundreds of thousands of people die each year from the consequences of hepatitis B infection, in the form of liver cancer and cirrhosis. But the GAVI Alliance has worked alongside the Chinese government and co-funded over 25 million vaccines to newborns, signficantly reducing Hep B infection. Given the huge population of China, deaths from Hep B are still widespread, but the Chinese government is now working on expanding the program across the whole country.

9. Pneumonia

Pneumonia is a leading cause of childhood mortality, killing 18% of the 6.9 million under-5s that died in 2011. The type-b strain of the Haemophilus influenzae bacteria (Hib) is one the main causes of such pneumonia, along with Streptococcus pneumoniae, which it interacts with.

In the 1990s, only one low-income country offered the vaccine to Hib. GAVI, a partnership that promotes vaccinations, then campaigned and presented strong evidence as to the benefits of the vaccine. Governments responded: “By 2011, nearly all GAVI-eligible countries had introduced Hib vaccines with GAVI support, immunising a cumulative 124 million children and preventing an estimated 697,000 future deaths.”

10. pertussis (whooping cough), 11. pneumococcal disease/pneumonia, 12. rotavirus diarrhoea, 13. yellow fever

Vaccines/treatment of these have all been significantly funded by the GAVI Alliance, which is supported by government aid (including the UK) and private philanthropists. It raises funds by selling long-term bonds backed by donor governments, meaning money is immediately provided by investors in those bonds.

14. Reduction in burden of Schistosomiasis (and other parasitic worms)

Schistosomiasis is a parasitic worm estimated to kill up to 280,000 people due to organ damage, though it probably kills closer to 40,000. It also contributes to malnutrition and causes pain, fever and anaemia. Schistosomiasis is still widespread, infecting several hundred million people globally. But there is a cheap and effective treatment, and given the success of reducing the burden of other parasites such as guinea-worm disease (see above), it is plausible that the coming decades will see a large decline and perhaps eradication of schistomiasis and other tropical parasitic worms.

Deworming drugs cost around half a dollar (~£0.30) per person treated, according to GiveWell. Studies in Burkina Faso, Niger, Uganda, and Burundi by the Schistosomiasis Control Initiative (SCI) report significant declines in parasite prevalence and intensity after treatment with these drugs. There is also evidence from Kenya that deworming is by far the most cost-effective way to increase primary school attendance. In Rwanda, recent reports state that the prevalance of schistosomiasis infection has fallen by over 80%.

-The Schistomiasis Control Initiative, run from Imperial College London, has received significant funds from the Gates Foundation, as well as the US and UK governments. But private donations have also made important contributions. And for good reason; the SCI is another highly-recommended charity according to GiveWell and Giving What We Can, demonstrating its cost-effectiveness, commitment to transparency, and ability to properly use any additional funds it receives. You can donate to the SCI here.

But what about overpopulation?

A very common concern is that by reducing mortality, these efforts are simply contributing to overpopulation. There are two key points in response to this:

Firstly, as this World Bank article highlights, probably the biggest influence on fertility rates (how many children a woman has) is childhood mortality. If you reduce child mortality, adults have fewer children (see box 2 on page 11 of the article for a summary). And the wonderfully enthusiastic Hans Rosling presents this 3-minute video showing how fertility rates and childhood mortality rates have changed since the 1960s.

There are of course other important influences on fertility rates, including education and access to family planning/contraception, but childhood mortality appears to be more influential than each of these. But the second point is that these diseases don’t just kill: they often also cause serious physical weakness, mental exhaustion and disability. This makes it much harder for children to receive good education in the first place; children can’t access school or are unable to properly concentrate once there, or the teachers themselves have the same problem.

Continuing to reduce the burden of disease should therefore speed up a ‘demographic transition’ whereby fewer children are born in the first place.

Furthermore, these diseases impact the economy both in the short-term (seriously reducing the amount and quality of work that can be done) and in the long-term (i.e reducing quality of education and hence ability to grow businesses successfully when the children grow up).

The University of York’s RAG international charities: a good choice?

Background

Each year universities across the UK take part in RAG events. RAG is a ‘backronym’ of  ‘raising and giving’. Students engage in a range of activities and adventures in order to make as much money as they can for selected charities. Last year, the University of York RAG campaign raised a very impressive £80,000 which will be distributed to the charities selected by the student body.

This selection process initially involves charities applying to receive funding. The applications are then reduced to a short-list by the RAG team, before all students have the opportunity to vote for the charities they prefer from this short-list. This year, 2 local, 1 national, and 2 international charities were selected to receive funding.

I am skeptical about the process used to select these charities. And given the amount of money involved, having an adequate selection process could potentially be the difference between life and death for many people.

It’s understandable that the University wants to donate to local and national charities, as these are ones that will benefit the University’s standing in the local community, and will engage students on issues that may affect their own lives, or their friends and families. But when creating a short-list of international charities, clear and precise criteria must be used to ensure a worthy choice is presented to the students to select the winners from.

What Criteria Should We Use?

The first and most prominent criterion should be cost-effectiveness. As Giving What We Can point out, some charities can be as much as 1000 times as effective as others. So if RAG donated £100 to one charity, this could have as great an impact as donating £100,000 to another. Given that each charity can expect to receive £5-10k, it’s easy to see the importance of intelligent, targeted donations. Other important criteria for charities should be transparency and accountability (i.e. willing to share information about their expenditure ) and room for more funding. (i.e. actually have goals that can benefit from extra finances). These are the criteria used by GiveWell to rank the charities they review.

WaterAid and Medecins Sans Frontieres

This year’s international charities selected by the University of York are Water Aid and Medecins Sans Frontieres (MSF). So, how well do they meet the above criteria?

GiveWell has recommended MSF for their disaster-relief efforts. They are also described as being “unusually transparent”. However, despite this positive view of MSF, GiveWell do not consider them to be cost-effective overall, at least not compared to their top charities

GiveWell contacted WaterAid with the intent to thoroughly review them. However, they have now been ‘deprioritized‘. This means that subsequent investigations revealed the charity was unlikely to meet the criteria to be one of their top charities, possibly because WaterAid were unwilling/too slow in providing responses to their queries, or because they were unable to provide strong enough independent evidence of the effectiveness of their work.

Giving What We Can are also skeptical about the cost-effectiveness of water-related construction programs generally (building “boreholes, stand posts and dug wells, or infrastructure that improves sanitary conditions, such as sewerage, septic tanks and latrines”). They claim that “their cost-effectiveness has been estimated as less than a tenth that of some other ways of promoting health”. However, they are much more optimistic about programs that seek to improve behaviour regarding sanitation and hygiene. Perhaps WaterAid will eventually show that their work in this area is as cost-effectiveness as the top recommended charities. They do not yet appear to have done so.

Conclusion

Though WaterAid and MSF have undoubtedly made improvements to the living standards of a large number of people, the top-rated charities would likely have aided many more, and to a greater extent. Whilst the University of York international charity recipients of RAG aid should not be determined entirely by the criteria I have discussed in this article (York may have long-established links to particular communities or causes), such criteria must surely play a large part.

I would therefore encourage the RAG team to clearly publish the criteria they use, and the weightings for each one, in order to apply pressure onto charities to demonstrate their evidence of effectiveness, their accountability and their costs. Ultimately this will help us determine what form of charity works well and what doesn’t, and hence allow us to improve as many lives as possible.

The killing of police officers is not an act of ‘pure evil’, Mr Cameron.

Prime Minister David Cameron has described the murder of 2 policewomen today as an act of ‘pure evil’.

Clearly, he could do nothing other than seriously condemn the shootings. Yet whilst the use of the phrase ‘pure evil’ may solely be intended to demonstrate how seriously he takes the situation, it is also not particularly helpful.

Why? Because it encourages and promotes ‘good vs evil’, black-and-white thinking. It ignores any attempt at understanding why such crimes are committed, and how they can be prevented. After all, if someone is pure evil, then there is nothing that can be done to change their behaviour. Education and poverty reduction can’t combat pure evil. Only the mystical Forces of Good can.

But the reality is we know that crimes are committed for reasons. Lack of hope for the future, anger, depression, hatred. Even because of boredom and for personal pleasure. Committing murder because of boredom might sound like pure evil, but again, there will be deeper reasons as to why someone decides to relieve their boredom by killing, rather than seeking an alternative. Psychopathy/lack of empathy for others, for example. This in turn has genetic and environmental roots such as certain gene variants (e.g. the monoamine oxidase A gene) combined with serious neglect during childhood.

Dismissing even the worst perpetrators as ‘pure evil’ does not encourage people to think about the causes and reasons behind actions, and fails to acknowledge that behind every murderer there is a person, and behind every person, there is, in the right circumstances, a murderer.

Riding a horse is as dangerous as taking heroin

What’s wrong with the following argument?

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P1. In the UK, heroin is a Class A drug.

P2. Ecstasy is also a Class A drug.

P3. The classification of a drug represents the level of harm it causes to individuals and society.

P4. Horse riding causes at least as much harm as ecstasy.

C. Therefore, horse riding is as harmful as heroin.

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Suddenly, I have a new-found respect for Britain’s successful Olympic horse-dancing team. Who knew they were taking such risks?

The problem with the above argument is at premise 3.  The classification of a drug is supposed to represent the level of harm it causes, but in practice it doesn’t. Why not? Primarily because politicians ignore scientific evidence on drugs. They prefer to appear tough on drugs, in order to please the tabloids. The tabloids in turn significantly under-report deaths from drugs such as paracetemol (reporting approx 1 in every 250 deaths) compared to ones like ecstasy (reporting almost every single death).

This means the classification of a drug loses any value as a signal as to how harmful it is. You might as well take a Class A drug, because being Class A says nothing about how harmful it is.

Some people argue that no matter how harmful something is, as long as people are aware of the risks, then we should be allowed do whatever we want to our own bodies. This is a view I am sympathetic towards. However, as long as governments take the view that they should tell us what we can or cannot put in our bodies because of the harm it causes, at the very least they have a duty to ensure the law is consistent with such harm.

GM Crops: ban them, but only if you also want to ban peanuts…

…and milk and eggs and seeds and soy, wheat, fish, shellfish, fruits, vegetables.

Actually, ban any food with any non-human protein in. It all has the potential to cause a serious allergy. Whether it is genetically modified or not.

The ‘health risks’ argument that is used to oppose each and every GM crop is, for the most part, absurd. Yes, there is a small possibility of them causing health problems. I would be surprised if no one ever develops a health problem in response to consuming a GM food. But the point is that we must see this in the context of the health problems and risks of non-GM foods that we already widely consume on a daily basis and that already cause problems to a small number of people

Now, this is not to say that other factors associated with certain GM technologies can’t contribute to health problems. A commonly suspected factor is the use of pesticides and herbicides. The most famous example is Monsanto’s ‘Roundup’ weedkiller. By modifying crops to be resistant to Roundup, farmers can apply it in greater doses, knowing that it won’t harm the crop. There are debates over whether this has actually increased or decreased overall herbicide use (use of more ecologically harmful herbicides than Roundup may have actually fallen as a consequence) and whether Roundup can have detrimental health effects.

There is also a genuine issue about consumers being able to avoid GM products for known allergies. Say, for example, a gene for a peanut protein that causes allergic reactions in some people could be inserted into wheat. If products were adequately labelled, one would think that consumers could easily avoid wheat products that contained such a protein. The concern is that crops would cross-pollinate, meaning that even the wheat that was not modified with the hypothetical peanut protein could acquire it.

But all too often anti-GM protestors take concern about one particular crop, such as Monsanto’s GM soy, and use it to accuse all GM products of having similar issues. Creating a herbicide/pesticide resistant crop is only one type of genetic modification. And risks of cross-pollination are dependent on the species involved and its method of dispersing pollen, so should be considered on a case-by-case basis rather than supporting a blanket ban on GM. This is particularly true given some of the potential benefits of GM crops. Here are a few upcoming GM products that involve traits other than increased herbicide and pesticide resistance:

1. Golden Rice.

~200 million people suffer from vitamin A deficiency around the world, and each year hundreds of thousands of children are estimated to die or become blind because of it.  This rice is genetically modified to produce beta-carotene, which is converted to vitamin A in the body. The rice can provide a significant proportion of the recommended daily intake, possibly 100%. The genes that have been introduced come from a soil bacteria and from maize/corn.

Interestingly, the intellectual property rights involved in creating Golden Rice have been waived for subsistence farmers, meaning they can earn up to $10,000 without paying royalties for growing the rice.

2. Wheat with a peppermint gene.

Globally, pests cause huge damage to crops; with estimates of 25-40% loss for many common crops. In the UK, aphids would cause a loss of ~£100m without the use of pesticides. Recent trials are looking at whether GM wheat, with a gene from the peppermint plant inserted, could deter aphids, possibly resulting in reduced pesticide use. The gene leads to production of a pheromone that plants already use in the wild to deter aphids. It also attracts a natural predator of aphids to further reduce their impact. It won’t, however, result in mint-flavoured bread.

3. Drought-tolerant corn.

This year’s droughts across America led to the loss of huge amounts of corn. This GM drought-tolerant corn could help reduce future impact of droughts; though probably not when they are as severe as this year’s. Future versions may have improved tolerance.

On a similar theme, a flood-resistant form of rice has been developed using non-GM methods by hybridisation of different strains of rice.  Although not GM per se, it did use some clever genetic technology in order to cross the strains. And one of the developers of this rice hybrid believes that GM technology will “give us a lot of tools for further improving rice, that we do not have now….[it]will give us a way to do that much quicker and much easier”.

What about corporate control of food?

Finally, many anti-GM protestors are concerned about the monopoly/private control of biotechnology and IP patents. There are some genuine issues about this, but what I say to them is this: support state-funded research.

This ensures relevant information remains in the public domain and is available for any entrepreneur to use. More research being publicly funded means less likelihood of a particular discovery or technology being patented. And the more biotechnology companies there are, the less likely anyone of them will have a monopoly on the market and be able to dictate the terms of use. Just don’t oppose the technology as a whole, and remember to consider the likely costs of not using it.

Are some countries more genetically inclined towards capitalism than others?

Claiming that there is a link between genetics and the economic system of a country will no doubt strike you as a preposterous hypothesis*.

I admit I’m skeptical about the following argument. But even if it’s wrong, at least it’s interesting. Here goes:

1) People who are more likely to support business and a capitalist system – entrepreneurs, inventors, investors and company CEOs – are deluded. They think the chances of their business, invention and investment being successful are much higher than they actually statistically are. They are overconfident and overoptimistic. They are willing to take more risks than is rationally justified. It’s probably a good thing some people are like this, otherwise the pace of technological creation and innovation would likely be much slower. But overoptimism also contributed to the housing bubble that contributed to the current economic crisis.

The thing is, most people are overly optimistic and overestimate their own abilities. One famous example is an American study where 90% of drivers believed their driving skills were ‘above average’. (See here and here for more examples, and buy Daniel Kahneman’s excellent book which covers a whole range of topics on human (ir)rationality and behavioural economics). But people who are more overoptimistic are more likely to become entrepreneurs.

2) Variation in how optimistic someone is, is significantly influenced by genetics; one study of Australian twins puts the genetic contribution at 36%. So environmental factors have an influence of around 64%.

3) Immigrants, given that they are taking a risk to move from one country to another, must be reasonably optimistic that they can make a success for themselves in a new country. They’re taking a risk by giving up everything that they know for a new culture (and possibly new language). This risk-taking certainly seems indicative of a mind-set similar to those of entrepreneurs, and there is strong evidence (see here and here) that many immigrants are indeed the entrepreneurial (genetic?) type, at least in America.

4) This implies that there is a genetic inclination towards capitalistic behaviour accumulating in certain countries. Perhaps countries such as America, which were founded by immigrants relatively recently, and continue to welcome them, have capitalism in their blood.

There are of course problems with this. It’s possible to find polls that purport to show that Americans are generally more optimistic than Europeans, but this is more easily explained by environmental rather than genetic factors (it might simply be that Americans feel cultural pressure to tell people, including pollsters, that they believe their life is improving, even if they secretly don’t believe this). Until there are more studies that look at genetic differences, this argument will have to remain a mere hypothesis.

If evidence for the link between genetics and inclination towards a particular economic system strengthens, and if it becomes possible for parents to select which genes they want their child to have, then one day we may find parents imposing their economic beliefs on their children not just by controlling the environment they grow up in, but also by controlling their genetics.

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* Did Steve tell you that, perchance?

The Eugenic Self-Extinction of Social Conservatism

A recent book by Chris Mooney argues that there is a neurological basis as to why many supporters of the American Republican Party seem to “believe more wrong things; appear more likely than Democrats to oppose new ideas and less likely to change their beliefs in the face of new facts; and sometimes respond to compelling evidence by doubling down on their current beliefs.”

I have not yet read this book. As such, I may be misrepresenting the views of the author, but based on the book description, it seems to me that his arguments are primarily targetted at the social conservatives in the Republican Party, rather the economic conservatives whose concern is limiting the size of the state (i.e what those outside the US would call supporters of economic liberalism).

This distinction is important. Economics is not a science; it is an art. There is no clear consensus on what is the best economic theory, partly because what one considers ‘best’ depends on your values. But even if one shares the same values, one can disagree with the means of promoting them. Strong rational arguments can be put forward for both reducing state investment and increasing it, if your agreed aim is promote economic growth. But interpretation of economic evidence is often confounded by too many variables to support one economic theory over another, at least not with the same level of confidence as one would need to reasonably support a scientific theory.

Mooney’s arguments may extend to more extreme economic theories. The book description claims he considers “why Republicans reject the widely accepted findings of mainstream science, economics, and history”. But non-mainstream economic theories exist at both ends of the economic-political spectrum. I suspect many Marxists are “less likely to change their beliefs in the face of new facts” just as much as many libertarians. (Though it should be said that someone adhering to non-mainstream economic theories does not necessarily mean they dogmatically ignore new facts. They could be right, and it’s actually the mainstream who have overlooked/ignored some essential facts).

Eugenics then. Where does this come into it? Well, let’s assume that Mooney is correct in claiming that there is a neurological/psychological basis for our political beliefs. Apparently “people more wedded to certainty tend to become conservatives; people craving novelty, liberals”. If one’s neurology influences one’s political outlook, it seems reasonable to infer there is also a genetic influence of one’s political outlook. I am not suggesting that anyone is born a Tory, Democrat, Liberal, Republican, Socialist etc. Clearly, one’s education, experience and upbringing play a hugely significant role. But genes will play a part too. [UPDATE: On his blog, Mooney does indeed list studies that suggest a varying degree of genetic influence on political preference]

Over the next few decades, it is possible that parents will, to an extent, be able to choose certain characteristics of their children. This could be done by using pre-implantation genetic screening of IVF embryos and selecting those embryos with the desired traits. Or it could be done by genetically engineering one embryo and inserting the genes for the traits the parents desire, rather than selecting from a group of embryos.

Social liberals are, apparently, more likely to “crave novelty”. Social conservatives are more likely to be “wedded to certainty”*. Historically, this can especially been seen with regards to changing attitudes towards sexuality and new reproductive technologies: consider the different stances on contraception, homosexuality, IVF, abortion. Thus, it seems likely that most social conservatives will strongly oppose using genetic engineering or embryo selection. Social liberals may be more willing to use it. If so, and they are able to select traits that they find valuable, they may seek to select genes that will encourage a socially liberal outlook. This could involve selecting genes that boost intelligence, since it appears that low intelligence, mediated via socially conservative ideology, predicts greater racism. But it could also mean selecting genes that directly influence one’s political leanings. Perhaps the genes involved in ‘craving novelty’ or being ‘wedded to uncertainty’ are related to having an appropriate development of fear responses; i.e not fearing someone merely because they belong to a new group whose clothes/language/culture/sexuality is unknown to you.

If this sort of selection occurs, then social liberals will essentially be self-promoting, and will thus increase their way of thinking within the population by having kids that are genetically inclined to think their way. Social conservatives, who won’t select for traits they desire because they generally have more ‘fear/distrust’ of the technology, will not enhance the social conservative genetic mindset. Any children they have will not deliberately be selected for conservative thinking. Thus, such children may grow up in a society that is increasingly overwhelmingly socially liberal. The liberal mindset will become the new social norm and any such children of conservatives will increasingly accept the liberal ‘status quo’; including the use of genetic technologies, perpetuating the selection of liberal ideals. Social conservatism as we know it will be extinct.

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*Socially conservative attitudes can occur across the economic political spectrum. For example, I suspect there are a number of socialists who would oppose any reform or reduction of the welfare state or (in the UK) of the privatisation of the National Health Service, even if there was strong evidence that such reform would benefit those who use such services.  This can be considered socially conservative just as much as those who consider themselves to be politically right-wing and are socially conservative in a religious or cultural sense.