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80,000 Hours Podcast
Village gossip, pesticide bans, and gene drives: 17 experts on the future of global health
04:06:50
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- [00:00]
Lucia Coulter
From the perspective of a manufacturer, they're only putting in a small amount of lead. 1% intuitively doesn't feel like that much.
- [00:09]
Varsha Venugopal
Right.
- [00:09]
Rob Wiblin
It's just a splash of lead. Just a little bit.
- [00:11]
Lucia Coulter
It's just a tad. Yeah. So I think it's not intuitive like how bad that could be. One way of communicating it is that if you had like a little sugar sachet, you know the type that you would get at a cafe to put in your coffee, if that was filled with lead dust and you sprinkled it across an area the size of an American football field, that level of lead loading would be sufficient to cause lead poisoning if a child spent time in that environment.
- [00:38]
Rob Wiblin
I see.
- [00:38]
Lucia Coulter
So a very, very small amount of lead can have these really toxic effects and that's not intuitive. That's pretty surprising. So I think that's probably how people think about it. But often manufacturers in some of our experience will move really quickly. Like sometimes days after we show them the results, they've ordered their non lead alternative ingredients.
- [00:59]
David Roodman
Hi listeners, Luisa here. You were just listening to Lucia Coulter, co founder of the Amazingly Cost Effective Lead Exposure Elimination Project. She joined the show in 2023 to share what she'd learned about rapidly scaling her intervention to multiple countries and contexts. I actually started my career at global health and development charities GiveWell and Innovations for Poverty Action. So I've been a big fan of our episodes with pioneers in global health since long before I became a host on the show. In this episode we share some of the most powerful and actionable insights from the 17 past guests who've worked on a huge range of evidence backed interventions to save lives and help people flourish. From improving agricultural productivity to using AI to eradicate malaria, to harnessing the power of village gossip to get kids immunized. You'll hear from James Tabandarana on whether we should use gene drives to wipe out the species of mosquitoes that cause malaria. Karen Levy on why push for sustainable programs isn't as good as it sounds. Sarah used to scuthri on whether more global health charities should shut down as hers did, plus many more. All right, I hope you enjoy.
- [02:16]
Interviewer (Rob Wiblin or host)
Development consultant Karen Levy on why pushing for sustainable programs isn't as good as it sounds.
- [02:25]
Rob Wiblin
You've been in the global health and development scene for a few decades now and have seen, I imagine, plenty of things in your time in if your game would be putting you on the spot, I would be excited to hear about any kind of common ideas or conventional wisdom in the field that you suspect might be misguided or perhaps is barking up the wrong tree in some way. Is that all right?
- [02:42]
Varsha Venugopal
Sure.
- [02:42]
Karen Levy
I'm always happy to share my very unorthodox views on some of these things. Yeah. So one of these concepts that I think we should interrogate a little bit is that of sustainability. And it's not that sustainability is bad, but I think that insisting on sustainability, making it a prerequisite of support for a particular program or policy, can really distract us from what matters or what should matter. And in some ways, I think that over privileging sustainability in assessing the effectiveness or cost effectiveness or the extent to which we should prioritize a particular intervention can in some ways be almost like the moral equivalent of, you know, to draw on Peter Singer's famous analogy of saying, well, a lot of kids drown in this pond and since we don't have a plan to save them indefinitely into the future, we shouldn't save this one now. And similarly, you know, if I told you that for some reason we were going to have to say, stop manufacturing a particular vaccine in five years, would we just stop giving that vaccine now? If that vaccine is truly effective and cost effective, well, then we should grab all of the impact that we can while we can. So what people usually mean is, how is this program going to continue after whatever initial funding is given has ceased? But unfortunately, I think what people often really are asking is, how are you going to create a perpetual motion machine? Right. And in high school physics, I was taught that there's no such thing as perpetual motion. And so I sort of feel like we, we're kind of collectively trying to defy the laws of nature here. A lot of the problems that we seek to solve are going to require long term sustained investment. And so if a donor doesn't want or is not able to provide that support for a long period of time, that's fine. But then I think really the conversation we should have is how are we going to shift the coverage of this to. To some other donor or some other source of funds and not like, how are we going to put in a little money and then it's going to kind of create an engine that's going to then fund itself. And I think we should be thinking about how long do we think a particular program or a particular problem is going to require resources? Is this a permanent need? Right. Is this something like basic education, which needs to be funded essentially indefinitely, or, or is this something like deworming, which I don't want the Kenyan government to have to sustain a deworming program 20 years from now, I want them to not have a worm problem anymore. Right. Is this something we think with sufficient investment now, we could really move the needle on over the next five to 10 years? We may find that identifying a highly cost effective solution, funding it reliably for 10 years, 15 years, is way more cost effective than constantly starting and stopping and reprioritizing and dabbling in various pilot programs that never get continued. Because we kind of have a little bit of magical thinking that they're going to somehow just perpetuate themselves. Now. There are some examples where that can be done. There are some programs that can ultimately rely on market mechanisms. That's terrific. Right. And that can be a highly leveraged investment for philanthropic funds. But a lot of the work that we do, a lot of the problems that we seek to solve require the provision of public goods, you know, goods and services that will not have market based solutions that are just going to require ongoing investment.
- [06:56]
Interviewer (Rob Wiblin or host)
Economist Dean Spears on the social forces and gender inequality that contribute to neonatal mortality in Uttar Pradesh.
- [07:06]
Dean Spears
So my work is about babies in India and health and survival at the start of life. So I work in a place called Uttar Pradesh, which is a state in India with 240 million people. One in every 33 people in the whole world lives in Uttar Pradesh. It would be the fifth largest country if it were its own country. And if it were its own country, you'd probably know about its human development challenges because it would have the highest neonatal mortality rate of any country except for South Sudan and Pakistan. 40% of children there were stunted. Only 2/3 of women are illiterate. So Uttar Pradesh is a place where there are lots of health challenges. And then even within that, we're working in a district called baraj where about 4 million people live. So even that district of Uttar Pradesh is the size of a country. And if it were its own country, it would have a higher neonatal mort than any other country. In other words, babies born in Baraj district are more likely to die in their first month of life than babies born in any country around the world. So it's a place where there's a lot of good that could be done.
- [08:14]
David Roodman
Can you talk about why neonatal mortality is so high in Uttar Pradesh?
- [08:20]
Dean Spears
So around the world, prematurity and low birth weight are the second largest killer of children. But in India, they're the first killer of children. And it's a particularly large challeng in Uttar Pradesh, babies that are born too small don't have the ability to do as well as they need to do. And there are a lot of babies that are born underweight here, in part because moms are so underweight. So in short, a huge part of the problem is a lot of underweight babies.
- [08:51]
David Roodman
Right.
- [08:51]
Lucia Coulter
Okay.
- [08:52]
David Roodman
I think of India as being middle income and doing like reasonably well on lots of these things. And I'm really, really taken aback that it's actually, yeah, I guess one of the worst in the world on neonatal mortality. Do we understand why that is?
- [09:08]
Dean Spears
Yeah, it is surprising that there's so much neonatal mortality in India. And the thing to keep in mind is that it's not just India, but there's a lot of differences within India. And it's in particular in this northern India area. For example, Uttar Pradesh and Bihar are where there is a lot more neonatal mortality than you would expect. And in this district where we work, about a third of the moms are underweight in the sense of having a body mass index below 18.5. And so why are moms underweight? Well, some of the reasons that moms in Uttar Pradesh are underweight are the reasons that sort of everybody in Uttar Pradesh has worse net nutrition than they might, such as the disease environment and poor sanitation. So moms and babies and dads all sort of live in a place where, you know, sanitation and yes, there's still open defecation here, mean that are exposed to germs that use up their nutrition, that SAP their nutrition and their energy through diarrheal disease or just fighting infections. But it's not just the poor sanitation and disease environment that's causing so many moms to be underweight. Very importantly, it's also social forces like gender inequality and the moms being socially low ranking people.
- [10:23]
David Roodman
Can you say more about that?
- [10:25]
Dean Spears
Yeah. So mothers in India tend to have their babies at younger ages, unlike in, for example, sub Saharan Africa where childbearing careers are more spread out in age. A lot of the babies in India are born to moms in their early 20s. And that's a time where women in India tend to be particularly likely to be underweight. You might just be thinking it's a poor country, that's why there's undernutrition. But there's more undernutrition in India amongst, you know, women of childbearing age than in, for example, sub Saharan Africa or the rest of the developing world. And what we see in India is this distinctive pattern where, especially in a place like Uttar Pradesh, the youngest women, you know, in their early 20s are particularly likely to be underweight and as they get older, gain more social status, have children, they become less likely to be underweight. So the likelihood that a woman's underweight falls in age in a way that we just don't see in the same way in the rest of the developing world. So India has this double challenge where mothers tend to have babies young and that's when they tend to be underweight.
- [11:38]
David Roodman
Right, right. And why is it that this is happening in India and not in countries in sub Saharan Africa, for example?
- [11:46]
Dean Spears
I think a very big reason is social status and women's status and the sort of hierarchy that you find especially in traditional households. Not all households are like this. But let's zoom in on a special case that it's easy to learn, which is joint households. And so Diane Coffey and Ritika Khera and I wrote a statistical paper about learning from joint households where you have two brothers, they grew up together into adults, they got married and they all lived together. And so in a household like this, the wife of the older brother is socially higher ranking than the wife of the younger brother. And the wife of the younger brother, the lower ranking daughter in law, is expected to do more work for the family and is later in line for getting the food she needs to eat, even during pregnancy. And so that's a situation where we can see an effect of a difference in women's social status, even comparing, you know, cousins, their kids who live in the same family, live in the same house, live in the same village. And so a lot of things would be held constant. So what do we see? Well, we do see that the lower ranking daughters in law are thinner and that's even though they have the same height. And so it's not about their early life nutrition, it's about what happens to them in adulthood.
- [13:10]
David Roodman
Interesting.
- [13:11]
Dean Spears
Yeah, it's like we have a little experiment here. We can look in these families as petri dishes to see holding these other things constant. What's the effect of mom being underweight for these social reasons?
- [13:25]
David Roodman
Yeah.
- [13:25]
Dean Spears
So what is the effect? Well, we see that the children of the lower ranking daughter in law are more likely to die neonatal deaths, and we see that they're more likely to be stunted and so small in other ways. And so in a situation where we're pretty sure that the difference in maternal nutrition is coming from these social forces, we're seeing it all the way through into neonatal mortality.
- [13:50]
David Roodman
Hmm, that is fascinating and depressing.
- [13:54]
Dean Spears
Well, I mean, I'm optimistic that in the long run it Won't always be like this that we're going to. It is the case, especially in other parts of India. Maternal undernutrition has gone down. These things are changing over time. A few years ago, 35% of women in Barit were underweight. In the most recent survey, only 30% of women in Baraj are underweight. So it's moving in that direction and hopefully in coming decades, this will not be such a challenge anymore. In the meanwhile, there's going to be a lot of low birth weight babies in Uttar Pradesh who need this sort of professional nursing.
- [14:34]
Interviewer (Rob Wiblin or host)
Charity founder Sarah Eustace Guthrie on what we can learn from the massive failure of Play Pumps.
- [14:41]
Sarah Eustace Guthrie
So for people who aren't familiar, Play Pumps is this charity where they had this really exciting idea which was you need to draw water from wells in many low and middle income countries. And often this involves a lot of laborious pumping that women especially have to do. And so they designed this play structure where the idea was kids play on the play structure and that like automatically pumps the water. And this was a really exciting idea. It just has this kind of intuitive appeal.
- [15:11]
David Roodman
Super wholesome.
- [15:12]
Sarah Eustace Guthrie
Yeah, yeah. It got huge amounts of money and then it turned out, whoops, it actually like doesn't work very well. And then EAs love to hold this up as, as an example of, oh, look, like things in development often don't work. But I think when I started digging into this example I was like, wow, this is even worse than I thought it was because it wasn't just that this was something popular that was kind of like in magazine ads and people on the street started funding it. But like it got this big grant in 2000 and then grew in momentum over the next couple years. And you got to this point where Laura Bush announced a $16 million USAID contribution to Play Pumps and big celebrities were doing these benefit concerts and it was actually only once they had built like hundreds over, like maybe even over in a thousand of these play pumps that some of these reports were commissioned or started seriously circulating that like, that actually went and like figured out how well it worked. And like it seemed from the reports that it was like pretty easy to figure out that it didn't work that well. And I don't know exactly what had happened in the process, but clearly before making these big donations, organizations including orgs like USAID that require a ridiculous amount of reporting were apparently not requiring reporting on the most important thing, which is like, that this thing actually works. So when I started reading into this, it turns out that there's actually a bunch of different problems with play Pumps. And just for context, like a play pump costs about four times as much as like a regular hand pump. And sometimes what they did is they replaced the regular pump with the play pump. And then like the play pumps were really complex. Like they had a lot of parts and so like when they broke down, it was tough to repair them. So not only are play pumps less effective, but I think you could argue that they were actually a net negative loss for communities. Right. And so that I think is a really damning part of this. And I think it also goes to like the guy who founded Play Pumps, as far as I know previously, I think had been an advertising salesman. And I think this speaks to what we were talking about, about the incentives where like, in order to make this program happen and to make this big change happen to the lives of these people in low and middle income countries, like in many communities, they weren't at all consulted. This thing just happened that made their lives worse because some salesman was able to sell something not only to people on the street, but to some of the people making big decisions at the US's biggest development agency. And so to me, that speaks to the problems with current philanthropy. I think what charities have to do to be more accountable is to take more seriously this monitoring and evaluation to, for any intervention that they're doing, actually do some sort of proof of concept test where they can go out in the field and consult with potential beneficiaries, see if it's really helping them. But you can't just ask them, is this helping you? Because, you know, they, they might feel pressured to say yes. But see, is it really connecting to aspects of their life where it's meaningfully improving them? So that doesn't mean giving textbooks written in a language that the kids can't read. That doesn't mean giving laptops to kids where there isn't electricity or where their reading isn't very good either. It means trying to focus on the interventions that are meaningfully improving people's lives. Taking a serious look at, like, even some interventions that sound really good. Even interventions that look good in initial randomized control trials don't always scale. So you have to have this consistent skeptical perspective where you're running an organization and you're saying, we're so enthused to be running this organization and we trust that we all have great intentions here, but we also are going to be dedicating a meaningful part of our resources to checking up on, is this intervention a good idea? Is it still improving people's lives meaningfully?
- [19:06]
Interviewer (Rob Wiblin or host)
Economist Rachel Glenister on how randomized control trials are just one way to better understand tricky development problems.
- [19:16]
Rob Wiblin
So moving to RCTs in general and sort of the state of debate around how much we should rely on upon them, you mentioned that it's kind of a 50, 50 split right now in today's work. Do you think that's an appropriate split? Do you think that it should be all RCTs? What do you think is kind of the right balance as we try to figure out what is obviously a very complicated world?
- [19:39]
Imran Rasul
I think it's really important to say
- [19:41]
James Snowden
that all of us who have worked
- [19:43]
Imran Rasul
on randomized trials have never suggested that this is the only methodology that you should use. People criticize us for saying it's the only methodology, but Nobody who's done RCTs has ever thought that that's the right approach. I think the right way to see things is you have a toolbox of ways to answer questions, and the right tool depends on the question that you're asking. So I think we need good descriptive work to understand what the problems are. A lot of development programs just fail because they're trying to solve a problem that doesn't exist. They're just solving the wrong problem. So the first really important thing you've got to do is really understand what the issue is in any given area. So if we're worried about girls not going to school because of menstruation, well, let's start by finding out whether they actually don't go to school more when they're menstruating. That's a kind of really basic, obvious thing. But we actually need more work on that kind of understanding your context. Understanding the problem is really important first step. So when I started doing agriculture work
- [20:49]
James Snowden
in Sierra Leone, the first thing we
- [20:51]
Imran Rasul
did was work with the government to kind of do a really detailed analysis of what are the problems for smallholder farmers in Sierra Leone. Not rct, just kind of descriptive. And it turned up all sorts of interesting facts that kind of people weren't aware of. So I think that's really important. I think then doing an RCT is useful for answering a really specific problem, a really specific question. But I think the best RCTs are ones that test a theory. So they test something that's more generalizable than just this. Does this program work? It's asking a question about human beings. Here's an example. So I did a project looking at how to improve immunization rates in India, which was fantastically effective. It started with a first assessment of what are the health problems in this area. And only 3% of kids in this part of India were getting fully immunised. And given that immunization is one of the most effective things that you could do, that rate is just appallingly low. So there were a number of theories about why that could be. And a lot of people said, well, people here don't trust the doctors. They don't or not doctors, because you rarely get doctors in rural India or rural anywhere but nurses in clinics. So they don't trust the formal health system. There was also a question of, so the clinics are often closed. So is that the problem? Is it that when you go and take your kid to the clinic, it's often closed? Is it nurse absenteeism that's the problem? Or is it just a behavioral economics thing that you're happy to get your kid immunized but you'll do it tomorrow? So we'd read all this behavioral economics and we said, well, maybe we should look at that. But we also wanted to test these other ideas. So one arm made sure that without fail, there was someone to immunize your child and another arm did that, but also provide a small incentive. So, yes, we were testing a program, but we were also asking a more fundamental question, which is, why don't people get their kids immunized? And what we saw in the data is a lot of people got their kid immunized with one immunization, but they failed to persist to the end of the schedule, which already. That's just descriptive data. And it starts to tell you it's not that they distrust the system or that they think that immunizations are evil because they're getting their kid one immunization, it's more a question of persistence. Now, fixing the supply problem increased the number of people getting the first shot and the second shot. But again, it failed to fix this persistence problem. Where the incentive effect worked was it helped people persist to the end. And so that tells you that one
- [23:41]
James Snowden
of the big problems was this persistence problem.
- [23:43]
Imran Rasul
And it tells you a lot about why immunization isn't happening. Now, that project was completely impossible to scale. This was like economists designing logistics. It was a disaster. I mean, we learned a lot, but you would never want to actually do a program like this. The logistics was a nightmare, but it tested a theory. And so once you have that, you can think about what's the implementation issues, how do we implement this at scale? Because you better understand the problem. You want to use an RCT when you can test a specific problem and get an answer to why is an issue. It's an important question. You can answer it well and it has broader implications. But you also need to use other types of methodology when your question is of a different kind.
- [24:37]
Interviewer (Rob Wiblin or host)
Data scientist Hannah Ritchie on why improving agricultural productivity in sub Saharan Africa is critical to solving global poverty.
- [24:48]
David Roodman
You've written an article that makes the claim that low agricultural productivity across sub Saharan Africa is one of the most important problems this century. So I'm interested in digging into that and kind of what concrete solutions might make achieving it possible.
- [25:02]
Rachel Glenister
So I should preface this by saying that one of the reasons I think it's an important problem is I think it's very overlooked and underrated as a problem. And I think that the, because it's somewhat overlooked and like slightly complex, I'm like not going to pretend that I have all of the answers or solutions because I think there's open questions there that I wish people were paying more attention to. But my argument for why I think it's like one of the most important problems of the century is I think there's two elements to it. There's a very human element to it. So if you look at sub Saharan Africa, and I'm also aware that we're talking about it like regionally when like there's obviously like very large differences across the region. But if you look at sub Saharan Africa as a whole, around 40% of the population still live on less than 190 a day, like so below the international poverty line, which is like very low. And there's, there'll be like many more that are like not that far above it. And then if you look at the, the employment across the region, like more than half work in agriculture. And if you look at the poorest, so it's estimated that around three quarters of those that are living in the deepest poverty are farmers. So they work in agriculture. So basically what we're saying is that most of the world's poorest work in agriculture. And the problem they face is that they're often really small holder farmers. They don't have the capital or the money to invest in fertilizers or machinery or to expand their land. So they basically they need, they need labor. So they have basically it's often like a family run farm where everyone in the family has to contribute. There's no money to like invest in education elsewhere. So they kind of almost get trapped in the cycle where they, they don't get A lot from, from crop production, but everyone in the family has to work there to just like stay afloat. And there's basically, you get locked in. There's almost no opportunities externally to go elsewhere. So one of my core arguments is that if you're going to address global poverty, you have to increase agricultural productivity in sub Saharan Africa. There's almost no way of avoiding that.
- [27:20]
David Roodman
Right, right. And so the idea is so many of these people that are earning the least in this region, which has many of the world's poorest, are working in agriculture, but producing so little relative to, I guess, the land they have, that they're not kind of earning nearly as much as they could. And by increasing their crop yields, which at the moment they can't do because they just can't afford to invest in it, you could lift a bunch of people out of poverty. And that, I mean, yeah, that just sounds like a huge win.
- [27:51]
Rachel Glenister
And then there's also. So there's the obvious human benefits to it, but there's also the environmental benefits. One of the impacts of having low crop yields is that you just need much more land to grow your food. And that's going to be a particularly pressing problem in sub Saharan Africa because that's also where we're going to see the largest population growth in the next 50 years or so. So sub Saharan Africa is going to need to produce even more food. And if they don't increase crop yields, then that's just going to come from expanding land, often at the cost of forests. So there's a very strong environmental case for if you want to address deforestation and biodiversity loss, then you have to somehow increase crop yields.
- [28:33]
David Roodman
Right. I guess you've. Yeah. You've argued that the reason it's so low in sub Saharan Africa is because. Yeah. Both labor productivity and land productiv are both super low. So I wanted to talk about each of those in turn. Yeah. Can you explain what labour productivity is?
- [28:51]
Rachel Glenister
Yeah. So labor productivity is basically just how much money, or in this case, crops that you then sell for money you get out per unit of input, where here we're talking about per hour worked or per worker. So it's basically how much human effort you have to put in to get like a dollar value in return.
- [29:12]
Leah Uchesheva
Yeah.
- [29:12]
David Roodman
Right. Okay. And that could be because if you've got great machinery, your labor productivity might be high because you can use a tractor as one person, but do a bunch of productive work. Whereas if you don't have a tractor and you're using a hoe, your labor productivity Might be much lower because you can get less done. Is that the idea?
- [29:33]
Rachel Glenister
Yeah, exactly. So I often think about it in terms of tending a garden, where often it's really, really intense work from a human labor perspective of you really need to work really hard and see to it often. And often the amount you get back is not that much. In that case, your labor productivity is really low because you're working really hard and not growing that much. Which, if you're just thinking about your garden's fine, but if that's your livelihood, that's not good.
- [30:01]
David Roodman
Yeah, that makes sense. How does labor productivity in sub Saharan Africa compare to other regions?
- [30:09]
Rachel Glenister
So if we think if we use a metric for it as the amount of value you'd get per worker, so the economic value per person working on the farm, the average for sub Saharan Africa is half of the global average.
- [30:26]
David Roodman
Oh, wow. That is much lower than I would have guessed you would have said.
- [30:30]
Rachel Glenister
It's half of the global average, but it's 50 times lower than you'd get in the UK or the US I spoke too soon.
- [30:38]
Lucia Coulter
But that's much more.
- [30:39]
Rachel Glenister
No, it gets worse. Oh, God. Okay, so if you look at some countries within sub Saharan Africa, they're like half of the sub Saharan Africa average. So there you're Talking about like 100 times less than you get in the UK or the US that's hard to.
- [30:55]
David Roodman
Yeah, that's hard to even fathom.
- [30:57]
Rachel Glenister
So you, like, put that in context. Like the value that like an average farmer in the US might create in three to four days is the same as a Tanzanian farmer for the entire year.
- [31:10]
David Roodman
That is really mind blowing. Yeah. And it makes it super visceral to me why this would be a huge problem, both kind of economically and environmentally. Why is it so low in South Saharan Africa?
- [31:26]
Rachel Glenister
So I think there's a couple of reasons. One is that the farms are really small, so often the amount of crop or value you get out is quite low. And maybe we'll come on to crop yield. So low crop yields, you get not that much out. But you also, as you said, you can't afford machinery or you can't afford fertilizers or pesticides or things that you would basically substitute for human power inputs. It just means you need lots of hands on deck to keep the farm going and keep it at that baseline level of productivity. So you don't get much out and you just need lots of people working on the farm.
- [32:09]
David Roodman
Okay. And then the other thing that seems to be really low here is land productivity, which Feels a bit more intuitive to me. Is that basically how much crop yield you'd get from, for example, an acre of land.
- [32:25]
Rachel Glenister
Yeah, exactly. So it's like what we would, like, I think, what most people would call, like, a crop yield. So say we each have like a hectare to grow wheat. If you got 4 tons and I got 2 tons, your productivity would be. Or your land productivity would be twice what I get. So it's. Yeah, it's just how much you get from a unit of land.
- [32:46]
David Roodman
Yeah. And I guess I imagine things that factor into that are, like, some things that are intrinsic to the area, like, I don't know, quality of soil, just, like, naturally, or I don't know whether it's clay or not. But also, I guess things that you could do to the land like use fertilizers. Are there other. Other things?
- [33:09]
Rachel Glenister
Yeah, so, like, there's a couple of factors that come into it. One is, as you say, the quality of land. So, like, the texture of the soil, the natural nutrient density, like carbon content of the soil, like how well it drains, like, all of these affect how a crop will grow. But there are also ways that we can change some of those aspects. So we can use irrigation or drainage to determine how much water is in the soil, or we can apply our own nutrients through fertilisers. So there's like, natural conditions, but there's also inputs that we can use to change that.
- [33:44]
David Roodman
Cool, cool.
- [33:45]
Rachel Glenister
Okay.
- [33:46]
David Roodman
And then again, I'm guessing land productivity is much lower in South Saharan Africa. How much lower is it relative to other regions?
- [33:54]
Rachel Glenister
Yeah, so again, it's very low. Like, one way we can, like, compare is using, like, we would use, like, cereal yields because the most regions grow some cereals. So if you compare the average in sub Saharan Africa, it's about half that of India, which is less than half of the global average. So it's pretty poor. And then if you compare that to, like, richer countries, it's like four to five times lower. But then again, there are, like, countries within sub Saharan Africa that will get, like, half again of that regional average. So, like, there are some countries where you're talking about getting 10 times less per unit of land than in rich countries, which, again, makes the environmental point, like, really clear. Right. To grow, like, imagine if we, like, globally, we had to use 10 times the amount of land to produce our crops, right?
- [34:43]
David Roodman
Yeah. And why is that? Is it something particular about sub Saharan Africa and, like, the kind of, like, natural things about the soil and environment?
- [34:54]
Rachel Glenister
I don't think so. And the reason for that is that there are examples where some countries within sub Saharan Africa or even like for particular crop types, they can get good crop yields. Like, I don't think it's just an issue that's in sub Saharan Africa you can't grow, you just can't grow anything. I don't think that's the case. There are a couple of reasons why. Or like, like it's quite hotly debated as to like, what the issue is. There like some, there's like very obvious like inputs, like problems like can't afford fertilizers, can't afford irrigation. So there's like a range of like, they just don't have the inputs or seeds that they would need to do that. There's also this like, interesting hypothesis. I'm not sure how convinced I am by it, and I'll give the reason for that. But there's this hypothesis that like, rather than being a supply problem, there's also like a demand problem where say you're a farmer in sub Saharan Africa and you're growing to about subsistence level to feed your family and you don't have access to a market to sell any more than that. It's like either you can't get to the market or at the market, people can't afford to buy goods for you, then maybe you have no incentive to grow any more food than that and raise yields because you would have to invest in fertilizers and irrigation stuff, which if you can't sell the extra food that you're going to grow, then why would you do that?
- [36:24]
David Roodman
Right.
- [36:25]
Rachel Glenister
So there's this hypothesis that there's like a demand problem where there's like not accessible markets to sell more. One reason, like, I get that and I, I think there's probably examples where that's true. One reason I'm like, not completely convinced is that it's not even apparent to me that many farmers are actually reaching subsistence because so many within sub Saharan Africa are undernourished. They don't get enough food to eat. So it's not obvious to me that they're actually growing enough even just to feed and meet their basic needs themselves.
- [37:02]
David Roodman
Right, right. Yeah, okay, that makes sense. And I guess one thing I learned while reading your work on this in preparation for the interview was that most of the world actually used to have much worse labor and land productivity that was actually similar to sub Saharan Africa's. What were the key things they did to improve that Sub Saharan Africa, I guess, didn't end up doing.
- [37:27]
Rachel Glenister
Yeah, that's true. I think we think about these low yielding countries as outliers now, but for most of our cultural history that was just the norm, that was just the default soil. And like the basic reason there is that basically our farming was just at like the whims of nature. Like water came when it came, you couldn't really like control it. You can irrigate the soil. You had to just deal with the nutrients that were in the soil at the time because you couldn't add any more. Like what's really changed there is like one we've been able to invest in irrigation and like improve with seed varieties and stuff. But a big change for many countries and we kind of see this inflection point in yields was like the beginning of the Haber Bosch process in the early 20th century where we basically figured out that we could make our own nitrogen fertilizer which for most crops nitrogen was the limiting factor. It's why it wasn't growing anymore. But we figured out that we could add it when we wanted to add it it and that's been like a massive driver of increased crop yields and,
- [38:34]
David Roodman
and why was it possible for the rest of the world to take advantage of that, but not sub Saharan Africa?
- [38:39]
Rachel Glenister
Yeah, one is like an obvious thing is it just costs money. So the richer, if you, if you have more wealth then you can invest in that. Like for some other countries have been really successful in like subsidizing fertilizers because they realize that it's so important to like break this kind of poverty trap where so they've subsidized it so it's much cheaper for the farmer in the first place. There's also the pairing of like fertilizer inputs with like having the right, the right seed varieties. So like many countries have gone through this like kind of inflection point with basically genetic breeding of particular seed varieties that were really successful. Like we just haven't really seen the same in sub Saharan Africa. I'm not completely sure why. I think regionally it's just even from like agrochemical perspective, which has its critics. But like if you're looking for genetic breeding and of particular seed varieties and fertilizer inputs and stuff, like it plays a crucial role. And if you look at a lot of like agrochemical companies today, like sub Saharan Africa is just not even on the radar. Like some of the big companies for example, they'll do like regional reports and have like regional divisions for some of them. Like it doesn't even warrant its own region. Like it's Lumped in with Europe.
- [40:02]
David Roodman
Oh, that's really depressing.
- [40:03]
Rachel Glenister
So it's basically what they're saying there is that like Europe and North America and Asia and to some extent South America make loads of, make us loads of money and Africa doesn't therefore, like, so we'll just lump it and move Europe and report it under the European numbers. So I think part of my motivation for highlighting this as a big problem is to somewhat shift the focus.
- [40:28]
David Roodman
Yeah, no, that makes tons of sense. Because if they were able to catch up to other regions on kind of both labor and land productivity, how much of a dent could that make on the issues at stake? So I guess poverty, hunger, wildlife destruction,
- [40:43]
Rachel Glenister
I mean, it would be massive. Even if you do projections just even out to 2030 on like where the number of people that will live in extreme poverty, like most of them will be in sub Saharan Africa. And as I said before, like 3/4 estimates that 3/4 of those that are living in the deepest poverty are farmers. Like, my, my argument is that we're not going to address global extreme poverty unless we fix this.
- [41:09]
David Roodman
Right? Right.
- [41:10]
Rachel Glenister
And to me, that's like arguably our most pressing problem we face. So it's just not possible without doing that. There's also the obvious argument that that's also where population growth is going to be happening most over the coming decades. And already like around 20% in Sub Saharan Africa don't get enough calories every day. And that's if they, if we don't improve crop yields there, that's just going to get worse as the population grows. And finally the environmental argument. So actually, some of my colleagues at Oxford University basically modeled what would happen to habitat loss for different species out to 2050 and what we could do about it. One of their key findings is that in sub Saharan Africa there's going to be, if things don't change, there's going to be a lot of deforestation because of low crop yields. But what we can do, and actually this links back to the question of is it just like maybe sub Saharan Africa just doesn't have the land and stuff to do this? Researchers can also calculate what they call attainable yields, which is what yields these countries could achieve if they had the right technologies and fertilizers and stuff. And the estimates come out that they could around triple their current yields just
- [42:38]
David Roodman
by changing, like how much fertilizer they're able to use, the irrigation technologies, they're able to use that kind of thing.
- [42:45]
Rachel Glenister
Basically using existing technologies that we have in a good way. They could Basically triple yield. So it's not that this is like, it's not that this is not addressable.
- [42:55]
David Roodman
Right. It's not a pipe dream.
- [42:56]
Rachel Glenister
Yeah.
- [42:57]
David Roodman
Concretely it sounds like the way to achieve that is like doing whatever these scientists found was best going to improve yields in terms of whatever these technologies are that would make the biggest dent. I guess I'm both interested in which technologies were those and also how we actually get those used given that it's not happened yet.
- [43:22]
Rachel Glenister
I don't think there's one single thing. I think there's a bunch of low hanging fruits and it's very context dependent. I've seen very good evidence that like one of the lowest hanging fruits is irrigation, the other one is fertilizers. Like as I said, many other countries have heavily subsidized fertilizers, at least for a brief period of time until you can almost like break that deadlock that has come with other issues on the other end. So you often find countries that have like really heavily subsidized fertilizer now like over consume the most because they're so cheap. Like farmers just put as much on as they can. But there's I think there's like really low hanging fruit there. Again, as I said, I think investment from like Agritech in this region is really important to me. It just seems very obvious that if you could get that market going that's massive. I think it needs to be like very early investments, either at a very high discount or subsidized in some way. I definitely think my suggestion here to some is controversial because there are controversies around the way that many of these companies behave in these markets.
- [44:37]
David Roodman
How so?
- [44:38]
Rachel Glenister
I mean there's always the big backlash against Monsanto, for example, where they basically try to create a monopoly. And I think there would be concerns that some of those relationships could be like quite exploitative in the end. Where basically Agritech companies create seed varieties that only work with a specific fertilizer that then they sell and then they. You could almost imagine farmers getting stuck in another trap. So I'm very aware of that and don't want to overstate that. Like this is like some easy solution that doesn't have issues. But I think to me it seems, it seems clear that we're not going to massively increase agricultural productivity there in the region without some of these investments.
- [45:21]
David Roodman
Yeah. So what does it look like for this to go really well? Who has to do what and then how does that trickle down to changing these outcomes?
- [45:33]
Rachel Glenister
I mean the big players are Obviously the country governments themselves and they are like, I get that it's difficult when your finances are already constrained of how to allocate resources. But to me it just seems like this is just like a really key fundamental problem and these economies are not going to grow significantly until they address the problem.
- [45:55]
David Roodman
And those governments are having to do things like subsidize some of these inputs or some other types of programs that address, I don't know, I guess the biggest issues.
- [46:06]
Rachel Glenister
Yeah, there's one is subsidizing or promoting the inputs. One interesting dimension is the, the, the, the market demand problem where like it's how you create an environment either within country or internationally where there is just a really strong market. And I think some of that can come from domestic governments. But I think there's also like an international role to play there where you can for example change trade tariffs to in some way where you can give preferential treatment or even just like equal the playing field a bit. It such that there's also larger domestic markets and incentives but also much larger international markets for farmers to sell into.
- [46:50]
David Roodman
Right. So lowering the tariffs on crops produced in sub Saharan Africa might make it so that there's a bigger market for those smallholder farmers to sell to. And then when there's a bigger market and they're earning more, there'll be this feedback loop where they're then investing more in imports.
- [47:07]
Rachel Glenister
I mean there's also just a large research dimension, like agricultural research dimension where as I said, I found the research on this quite murky in terms of really pinpointing this is how we have a big impact here. I think partly because it's just so heterogeneous across the region as you'd expect. But I think there is just a large area for research on how particular soils affect the growth of these crops, like how different seed varieties fit in, what's the ideal combination of fertiliser and irrigation for example. So I think there's still lots of room for good research.
- [47:49]
Interviewer (Rob Wiblin or host)
Charity founder Lucia Coulter on the huge neglected upsides of reducing lead exposure.
- [47:56]
Rob Wiblin
How many times more damage is lead doing in countries that LEAP operates in as opposed to countries like the US or UK where most listeners like live.
- [48:04]
Lucia Coulter
So LEAP operates in low middle income countries and 95% of the global burden of lead poisoning roughly is concentrated in low middle income countries. So in low middle income countries the average blood level is around 5 micrograms per deciliter which is classified as lead poisoning. So on average almost children have lead poisoning. And in high income countries the average childhood blood lead level is around 1 microgram per deciliter. It's a bit lower than that in the U.S. and like you say, the data is not amazing anywhere on this, but it's about five times lower in high income countries. And the Flint, Michigan example is really stark. I think that was a huge crisis having 5% of children in Flint, Michigan with lead poisoning. But the fact that just Every single day 50% of children in low and middle income countries have that level of lead poisoning is really, really concerning, really troublesome. So we could think about it in terms of what would the impact be on the average child in a low and middle income country? The average child in a low or middle income country has a blood level of around 5 micrograms per deciliter. And that's high enough to cause health, educational and economic impacts. So a child with that blood lead level would have a reduction in IQ anywhere from around 1 to 6 IQ points, depending on which analysis you take. And then that in turn would will affect their future earning potential. They'll also have reduced educational attainment. There was a recent analysis by the center for Global Development that pretty conservatively concluded that that would be equivalent to around one year of lost schooling. And then it also causes an increased likelihood of cardiovascular disease and mortality from cardiovascular disease. And that could be as high as a relative risk of around 1.5 at the average level of lead exposure that children have in low middle income countries. That's according to a recent analysis of US data. And then on top of all of that, it increases risk of kidney disease, anemia, fetal health problems, behavioral disorders, ADHD, and possibly even mental health problems and dementia.
- [50:20]
Rob Wiblin
Yeah, we've known for at least 100 years that lead is poisonous. I guess we can kind of see that because France banned lead paint in 1909. They were one of the first countries to do it. But nonetheless, they thought it was sufficiently dodgy that there was lead going in paint in houses, that they banned it 110 years ago. And apparently even the ancient Romans suspected that lead was bad for you. I guess they probably didn't have gold standard randomized controlled trials here, but they probably noticed that people who worked in lead mines ended up with extreme health problems and figured out that lead was probably bad for you. Is there a simple reason why this problem hasn't already been solved? Why didn't we know in the 19th century to stop adding lead to stuff that people were going to be eating?
- [50:58]
Lucia Coulter
I think it's a good question. I think it's probably not that simple an answer. I think to start with, lead is just a really useful metal. It's abundant, it's malleable, it's durable and its compounds make loads of really helpful things like strong glazes, bright pigments, anti knocking fuels. I think in the 20s the industry in the US described lead as a gift from God because it's just such a great thing. So I think people will just keep using it unless they aren't able to, unless they're strongly incentivized not to. I think another reason is that there is extremely low awareness of both the prevalence of lead poisoning, the harms of lead poisoning and the sources of exposure. Low awareness kind of generally, but also among important decision makers, important institutions and low middle income country governments and funders. I guess that leads to the question, like, why is the awareness so low?
- [51:56]
Rob Wiblin
Yeah, I mean, maybe this is something that a historian should be looking into is understanding. Maybe they could find some mentions in parliamentary records or something from the 19th century of people raising the question of whether lead was safe. There must have been some stuff written about it if it was banned in France in 1909. But why is it that that didn't win the day? Why is it that industry that wanted to add lead to things won out the debate?
- [52:16]
Lucia Coulter
Yeah, I always wonder if one part of it is just like the really invisible nature of lead as a poison. I mean, of course impacts aren't invis millions of deaths and trillions of dollars in lost income, but the fact that lead is the cause is not apparent. It's not apparent when you're being exposed to the lead. The paint just looks like any other paint. The cookware looks like any other kind of cookware. And also, if you are suffering the effects of lead poisoning, if you have cognitive impairment and heart disease, you're not going to think, oh, it was that lead extension. It's just not going to be clear.
- [52:47]
Rob Wiblin
I guess it's an issue with. We tend to treat specific acute diseases and be very aware of that, but then everyone's suffering. Some relatively small chronic impact just doesn't really rise to the level of anyone's notice and cause a public outcry.
- [53:00]
Lucia Coulter
Yep, exactly. And the symptoms aren't like specifically characteristic of the cause. It's not like, you know, malaria, you get cyclical fevers. It's like, obviously something going on here. I think that's part of it as well.
- [53:12]
Interviewer (Rob Wiblin or host)
Malaria expert James Tebenderana on using gene drives to wipe out the species of mosquitoes that cause malaria.
- [53:21]
Rob Wiblin
What do you think of the idea of using gene drives to eliminate the specific species of mosquitoes that carry the malaria parasite. Yeah, I think there's an organization called Target Malaria who's working on research to figure out where this might be possible and whether it's a good idea. Basically the idea is here I think you release a bunch of mosquitoes that have been genetically engineered such that whenever they mate with a partner, all of the children, for example, could either be infertile or they could all be males or all be females or something like that.
- [53:48]
Lucia Coulter
That.
- [53:48]
Rob Wiblin
And then that means that if that happens every generation, then after a series of replication cycles they all die out because there's no females or no males left. And so largely the species will go extinct locally. This does have the implication that if you release some of these mosquitoes and as long as say they don't evolve to break this gene derived technology, that this could spread globally basically and eliminate that species of mosquito completely, which has proven slightly controversial with some people.
- [54:13]
Lucia Coulter
Yeah.
- [54:13]
Rob Wiblin
Do you want to talk about gene drives and Taga malaria? Yeah.
- [54:16]
James Tebendana
Gene drives are a novel intervention that certainly has a lot of potential. There's still a long way to go. There's quite a bit of research, especially epidemiological research that needs to be done to understand the potential impact. But I think the technology itself is very powerful and I think therein lies some of the risks.
- [54:41]
Rob Wiblin
Risk it's almost too powerful.
- [54:43]
James Tebendana
It's probably. Yeah, it's really powerful.
- [54:45]
Rob Wiblin
Yeah.
- [54:46]
James Tebendana
And you know the, of the gene drive systems, there's sort of low threshold gene drives and high threshold gene drives. So with high threshold gene drives you need a large number of mosquitoes released into the wild to have the impact. And then with low threshold gene drives you need a few mosquitoes to be released into the wild and, and really propagates itself. And then within those you have some gene drive that help, that once introduced will suppress the population of mosquitoes or insects. And then you have some gene drives that will modify elements within the mosquito or the insect to cause it to not be as efficient or not able to perpetuate a particular attribute. So I think in terms of the gene drives for mosquitoes, anopheles specifically, is that really. It's a low threshold type of gene drive and one that will cause suppression because of this double sex gene that creates a generation of infertile offspring and that continues to perpetuate itself until you actually sort of wipe out that particular species. And I think the studies that have been done in cages so far suggest that that is possible. And so it is certainly a very powerful tool. I guess the question that we will all have, and we see this
- [56:18]
Interviewer (Rob Wiblin or host)
in
- [56:18]
James Tebendana
nets and we see it in some of the other tools, is what will be the acceptance of national governments or communities to a technology that can be complex to understand. Yeah, I see the minute you get into genetically modified technologies raises eyebrows. It raises eyebrows and you have adopters, but you'll also have the skeptics. And I think that's one thing Target Malaria is conscious of. And they've spent a huge amount of time working with communities, working with members of parliament in some of these countries to understand what the legislative framework is and what kind of information the decision makers require for a policy to be adopted in terms of gene drive mosquitoes or gene drive insects in general. And then communities, how will they perceive these genetically modified mosquitoes? And I think they have, you know, they've really done some very good community engagement work, some studies, and I think they're starting to show that there are ways that one can communicate with both communities, but also decision makers that can potentially make this adoptable. That's one element. Now with this type of technology, you can't simply say, I'm releasing it in one country and it's not going to spread to the next country, it's probably
- [57:42]
Rob Wiblin
going to spread everywhere eventually.
- [57:44]
James Tebendana
Exactly, exactly. So not only do you need a country adoption, you probably need regional adoption. So if you release it in West Africa, then what is Ecowas going to think about it? If you release it in Southern Africa, what is Sada going to think about it? All right, so you have all these regional bodies, the African Union, et cetera, what is going to be their perception of gene drive genetically modified mosquitoes that are released? Because you really need the governance framework and the legislative framework that is regional rather than just country specific.
- [58:18]
Rob Wiblin
Yeah, totally right.
- [58:20]
James Tebendana
And that requires you to also be able to engage with all these communities. I'm not saying that this tool isn't powerful, this is a really powerful tool, but I think in its power lies some of its risk. And I think you have then the question, how do you turn it off either when you don't need it any longer, or as we know, with catastrophic risks in the future, something goes wrong and we don't expect it to. But if it does cross over into other insects unintentionally, how do you turn it off? And so I think there's the technology, but I think we also need the cross country collaboration and governance and we do need a good understanding as to what will happen if we have unintended consequences and we need to turn this technology off.
- [59:14]
Rob Wiblin
Yeah, I think there is a way of turning it off, as I understand. Unfortunately, I didn't look into this, but I think basically you would release new mosquitoes with like a gene drive. Gene drive. That cuts out and deactivates the other gene drive, basically. So there is an option, but it's like, it's challenging. Oh, it's like it's something we haven't done before.
- [59:29]
James Tebendana
Exactly. So you need the two happening almost concurrently, right?
- [59:33]
Rob Wiblin
Yeah, yeah.
- [59:34]
James Tebendana
Because this technology is certainly going to. I mean, let's see what happens when it goes into larger scale trials in different locations. But it certainly has potential.
- [59:45]
Rob Wiblin
Yeah.
- [59:45]
James Tebendana
And it could be an important game changer, maybe in the next 10, 20 years. But I think you do need the investment in understanding how to mitigate some of the risks of the technology so that we are able to describe both the technology as well as the mitigation of those risks to communities and governments who need to be on board for this to be introduced and have the impact that it could achieve.
- [60:14]
Rob Wiblin
Yeah, a lot of people worry about unintended consequences here or they're nervous about this technology. I think that's understandable. I'm a bit more of a risk taker maybe. And I feel a bit more like. I just want to say, to be frank, we're talking about like driving very specific species of mosquitoes extinct globally. We're trying to get rid of them because unfortunately they're the ones that carry this parasite. Parasite. However, we would in the process save 600,000 children's lives every year, prevent 200 million cases of this very unpleasant illness. It could be something that really does end malaria or at least dramatically reduce malaria. So the benefits we're talking about here are very large. And I think some people hear this and they're like, oh, you're getting rid of all mosquitoes. To be honest, I'm not sure that I would be that against getting rid of mosquitoes. Maybe there'd be other insects that could fill that niche that aren't as annoying as mosquitoes. However, that's not actually what's being suggested because there's tons of other species of mosquitoes that don't carry the malaria parasite and so don't have this problem. And likely, given that they are an extremely similar insect, they would probably just colonize the same niche in the environment that the Anopheles mosquitoes and so on are currently filling. So to me, it does just seem like the benefits greatly outweigh the costs on their face. So I would kind of like to see maybe a bit more hustle about figuring out how can we do this. And to some extent it surprises me, me that there hasn't been, say, one country that's been like, we want to get rid of malaria and we're just going to do this. And then that does have effects on other countries and maybe they don't like it, but it's something where a single actor could potentially do this for the whole world if they're willing to be unilateralist about it. And it's kind of interesting that that hasn't happened or that there's no proposal or that it doesn't seem like that's likely to happen anytime soon.
- [61:51]
James Tebendana
Yeah, I mean, Rob, there's like 3,500 species of mosquitoes. So. So getting rid of 40 specific species. I mean, as you know, with gene drives, you have to go species by species, species by species, right?
- [62:05]
Rob Wiblin
Yeah, certainly.
- [62:07]
James Tebendana
I think the benefits, I mean, there's 4 billion people at risk of malaria, right. I think if we ask those 4 billion people about how they would feel getting rid of these vectors, I suspect they will be keen not to be at risk of malaria. So the benefits, certainly in the short term and probably in the long term because of the value of a malaria free world. Remember, it's not just the disease, but it's also the economic benefits that will be had if we are able to achieve a malaria free world. So I think there's huge benefits and like you, I would be certainly a proponent of the risk risks. But that's you and me. We've still got to recognize that national governments, yes, and I suspect they will see the urgency, they will see the need, but at the same time, we have to recognize that they have to go through their own legislative process. It's not just going to be a minister of health policy. All right? This is about potential.
- [63:10]
Rob Wiblin
It's a big deal.
- [63:11]
James Tebendana
This is a big deal. Right. And I think we have to recognize that countries will have to understand both the benefits and understand the risks and providing the right evidence and at least a sense of what the potential mitigations are for the risks would really go a long way in the fast adoption of the technology so that we don't have a technology that we've shown we've proven, and then we spend another five years trying to get it adopted. I think what we all want is that by the time this technology is available, all right, countries are really just. Everyone's on board, everyone's on board, engaged communities, they are ready and the potential can be achieved. I mean, the history of malaria seems to be that you take 15 years from a WHO recommendation to a potential scale up of a tool. So there's this long period between a recommendation and scale up. We don't want that to happen with the next generation of tools that are so powerful, especially one like GeneDrive.
- [64:15]
Interviewer (Rob Wiblin or host)
Charity founder Varsha Venugopal on using village gossip to get kids their critical immunisations.
- [64:24]
Rob Wiblin
It seems like parents don't want their kids to die and the benefits of vaccinations are really big and they don't. The parents don't object to vaccinations. What's going on that's causing the parents not to really prioritize as a really high priority, making sure that their kids get the later vaccinations. Maybe they don't appreciate that, like one in every 20 or something of the children who don't get vaccinated end up getting these horrible illnesses and suffering severe consequences.
- [64:45]
Varsha Venugopal
So to put this in context for India, we have about 26 million children born every year and we have 16 million children that are completing the vaccination schedule. So we are talking about the remaining 10 million. So one of the big reasons we think, and there has been some research they drop off, is to do with time inconsistency argument. I think it's something referred to by Banerjee and Duflo in their book Poor Ikat as well. This whole idea that I value my present very differently from the way I value my future. Right. So even when I'm making decisions on exercising or gym, it's all something I'd rather postpone for all these other myriad intrusions on my time in the present. And I think some of that is what's at play for these parents as well. So caregivers may miss their appointments for various reasons. They could just be forgetting about them. They may not have the right information to accurately understand the benefits. We do know sometimes they don't know how many appointments they need to come for, or they just don't want to take a day off work, they don't want to deal with a crying child, they don't want to take the bus to go somewhere for vaccination. So all reasons which, possibly by small nudges in the margins, could be addressed.
- [66:02]
Rob Wiblin
Yeah. So their best guess is it's just the basic thing that we can all relate to of you put something off and you put something off because it's kind of a pain in the ass to do on no particular day. It feels like the day that you want to go and do the vaccine when it requires crossing town or. Yeah. Dealing with your baby not wanting to get an injection.
- [66:18]
Varsha Venugopal
Yes. And this is exactly where it's really important to reinforce that it's very different from COVID vaccine hesitancy or other kinds of vaccine hesitancy that may exist somewhere, which is possibly far more complicated and involves issues of trust. I mean, here we know because they've come in for the birth dose and at least one other dose, that they broadly trust that the vaccines and believe it's a public good, but for a myriad of reasons are then dropping off because of just being overwhelmed with their daily lives. So the gossip intervention is. In the original J PAL study, the surveyors were sent to a random set of 17 households and they asked several questions. But the main question is, if there was a fair in town, who is most likely to tell you about it? We then run an algorithm to identify the top customers or community influencers and the surveyors then go back to these top influencers and recruit them as immunization ambassadors. What we did as a result of COVID was pivot to a remote model which already brings down the cost significantly in that we call up a random set of households to identify these influencers and then call these influencers to recruit them as ambassadors. So compared to the SMS model, this model at the moment is still not as mature and we are still iterating to find the most cost effective way of doing this.
- [67:42]
Rob Wiblin
Yeah. Okay. So you identify a village. I guess it seems like a significant fraction of India's population is living in villages of 500 to 1000 people or so. Is that kind of what you're targeting?
- [67:51]
Varsha Venugopal
That's the standard ratio we're using? Yes.
- [67:54]
Rob Wiblin
Yeah. Okay. And so you call up a random bunch of households and you say, yeah, who would tell you about an event and then you pick maybe the person who is most often mentioned and get their phone number and then call them A. And then you say to them, what do you say on the phone? It's like an odd call to get.
- [68:08]
Varsha Venugopal
We have some standard language we use and in fact we are iterating with some of this which also seems to increase the success rates. But broadly it is saying that you have been identified as a community influencer and we would like you to be an immunization ambassador. There is no monetary cost involved in this. It is a voluntary exercise. We would be sending you regular reminders on immunization camps. Are you Willing to be an ambassador.
- [68:34]
Rob Wiblin
Yeah.
- [68:34]
Varsha Venugopal
So in more than 90% of the cases when people were contacted randomly, they were able to give us not only the name of an influencer but also their phone number. And then in more than 95% of the cases the influencers agreed to be to be ambassadors. The challenge we had was reaching these influencers, possibly because they are influencers. They're not around most of the times. It's unclear. That's just that. But that's the bit we are now iterating to try and call at different times of the day or different days of the week to get to them. The other bit was are these ambassadors then sharing the information? So one thing we did early on was give them a phone number that they could then share with parents and ask the parents to give a missed call to enroll into the SMS reminders program. And I think we had more than 30 people sign up in the first week, which again gives us some confidence that the ambassadors are sharing this information and people are receiving it and somehow responding to it.
- [69:34]
Rob Wiblin
Yeah. So just trying to build a better model of exactly what this looks like in my head. So do you know, are these cool people or very extroverted people or high status people in the village, like maybe someone who's involved in local politics? Do you know what kind of person we're talking about?
- [69:46]
Varsha Venugopal
That's a great question. So in the J PAL study they looked at both trusted people as well as community influencers and see the interaction of and it turns out it is the community influencer bit which seems to be causing the biggest impact other than the fact that we know about 18% of our influencers are women, which is kind of similar to the J PAL study. We are very curious to better understand the motivations of the ambassadors and why they take it on. And that's the kind of thing you don't get in an rct. So that's something we want to go there and interrogate further.
- [70:21]
Rob Wiblin
Yeah. Just to have a picture in the head of the magnitude of the benefit. You're saying it increases vaccination rates by 10 percentage points and that's about 27%. So huge magnitude. How large is the SMS reminder effect again? Separately?
- [70:35]
Varsha Venugopal
Somewhere between 3 and 7.
- [70:37]
Rob Wiblin
3 and 7%?
- [70:38]
Lucia Coulter
Yeah.
- [70:39]
Rob Wiblin
Okay, so I'm guessing the SMS reminders are a bunch cheaper because you're just sending texts and I guess they're probably easier to scale as well because you just have to get a bunch of phone numbers and then stick them in some piece of software that sends out Texts, text messages. On the other hand, it seems like the ambassadors have a larger effect size, maybe a more robust result in the rct. How do you kind of trade off this easiness of scalability and low cost?
- [71:02]
Varsha Venugopal
Yeah, so we know SMS reminders, you're absolutely right, are easier to scale up. In fact, in one of the two states we work in, Maharashtra, we already have a memorandum of understanding with the state government which allows us to rapidly scale up across the state. Having said that, we are quite aware that it's the Ambassador program, which seems to be having some of these large effect sizes, and we're really excited to overlay it on top of the SMS reminders program.
- [71:32]
Interviewer (Rob Wiblin or host)
Rachel Glenister on solving tough global problems by creating the right incentives for innovation.
- [71:40]
James Snowden
Market shaping is the idea of leveraging the power of markets to incentivize innovators to generate the innovations we need to solve some of the world's biggest problems. Now, markets have a lot of benefits. They help incentivize innovation. They develop products that people actually want to use. They aggregate information, but they also get things wrong. They're not very good at, at solving things where there are externalities like climate change. So the idea is to get the best of both worlds and incentivize markets to respond to the things where we really need them to respond to.
- [72:24]
David Roodman
Learning about this actually made me think of this blog post that a friend shared with me recently. So the blog post was by Jacob Trefethen, and it's called 10 Technologies that Won't Exist in 5 Years. So Jacob's the science policy grant maker at Open Philanthropy, and so he has kind of a sense of where science funding goes and how hard it is to make progress in some areas. And I found the blog post really moving and really tragic, and it feels relevant. So I wanted to share a couple of the technologies that he thinks won't exist. One relates to tuberculosis, which kills 1.5 million people a year, which is twice as many people as die of malaria each year. And according to Jacob, a tuberculosis vaccine that worked in adults is totally achievable, but he thinks for basically no good reasons, we won't have one in five years. Nothing related to the science will prevent us from getting there. Similarly, strep A kills 500,000 people every year. And again, a vaccine is achievable. Hepatitis C kills 300,000 people a year. Again, a vaccine is achievable. And yeah, it's really horrible. I definitely had the kind of intuition that diseases like this, that are this deadly aren't being we're not kind of creating the vaccines or treatments we need because the science is too hard. But when I learned that that's not the case, it just feels really unacceptable. Are these the kinds of market kind of failures that you're talking about? And if so, can you talk me through why they happen?
- [74:06]
James Snowden
Yeah, those are exactly the kinds of targets we need to do market shaping for. Actually, tuberculosis was one of the diseases that brought me into thinking about this many, many years ago when I first started working on trying to accelerate vaccines.
- [74:22]
Imran Rasul
And it took way, way, way too
- [74:24]
James Snowden
long for us to get a malaria vaccine compared to the huge death toll. There's a number of market failures going on. There's a number of reasons people don't invest in doing innovations for these kinds of problems. And one of them is that there's a lot of pressure to keep prices down once you invent something, and especially if it's really important for poor people. So it's a time inconsistency problem, we call it. You would be willing to pay for something in advance, but once it comes, there's a big pressure to keep prices down. And the patent system that we have to cause to incentivize people for innovation is really, really, really inefficient. It works by allowing companies to keep prices high to get a reward and a return on their investment. But if you're designing something for really poor people, you can't keep. Nobody's going to buy it when the price is high. So you have a small quantity at a high price and you make your money back. And then later you reduce your price and get it to lots of people or a vaccine where people are willing to pay a lot. When you get a, a drug that you're about to die of a disease, but a vaccine, you need a low price to get to lots of people. And that's not how our patent system is designed to work. It works by charging a high price to a small number of people, and that's just really inefficient.
- [76:05]
David Roodman
Okay, let's talk through a few specific examples of pull funding mechanisms. One example is an advanced market commitment or an amc. How do amc?
- [76:20]
James Snowden
So an advanced market commitment is something done in advance. You commit in advance to either buy or subsidize a set quantity of a product at a set price. So you're defining the market because the market is price times quantity. You're committing advance and you're defining what it is that you want to buy.
- [76:52]
David Roodman
Right.
- [76:52]
James Snowden
You're setting out, I will buy if you meet these criteria and it's legally binding, which is really important because people make, you know, there are all sorts of statements about I will do this green thing or that green thing, but this is like legally binding company commitment.
- [77:11]
David Roodman
Yeah, yeah, that does seem really important. I guess trying to be skeptical. It seems really hard for an institution to make funding plans when making advanced market commitments. You don't really know. Well, maybe you do know how much you'll end up having to pay, but you don't really know when. And I guess you don't know in the sense that it's possible. No one produces is the output. So maybe you'll pay zero or maybe you'll pay some capped amount. Is that not a deal breaker for some funders? It just seems like if I imagine government bureaucrats sitting and thinking about their budget, I wouldn't expect them to be able to say like maybe $2 billion in two to five years. Can they do that?
- [78:00]
Rob Wiblin
Yep.
- [78:00]
James Snowden
Okay. So it certainly makes life harder.
- [78:02]
Alexander Berger
Harder.
- [78:03]
James Snowden
Like that is absolutely clear. And it's funny because kind of one of the benefits is that you don't have to pay if it doesn't get invented. But actually that turns out to be
- [78:13]
Imran Rasul
quite complicated for governments to go with.
- [78:16]
James Snowden
So one thing is, well, philanthropists, they often have a bunch of assets of stock in the company that they founded or whatever, and then they're paying out money in their foundation every year. But they can actually use that stock of assets and put it to work now by stimulating innovation by saying, I'm willing to sell some of that stock and spend more in any given year if somebody comes up with this thing.
- [78:49]
David Roodman
Right.
- [78:50]
James Snowden
So I think philanthropists actually, it's not hard, hard to do it because they have a stock of assets that they're going to run down slowly. But if there's a brilliant opportunity and
- [79:02]
David Roodman
they're looking for good opportunities, they should
- [79:05]
James Snowden
be willing to pay more that year. Right. And now let's turn to governments because governments are important and I think we'll probably do more of this. Let's start with kind of the logical economic argument, which is if this brilliant cost effective opportunity comes along suddenly, you should be willing to borrow for it. You should just say, wow, we suddenly have a way to reduce climate change and that is incredibly cost effective and way more cost effective than other things we've been doing. Well, you know what, we should suddenly just do it and we should be willing to borrow for it because you set the price so that you will only be buying it if it is cost effective. So there's no risk, you know, it's going to be cost effective. So you should just borrow for something that has a high benefit whenever it hits. And then you can just borrow whenever it hits. That's the logical economic argument. Is that actually how budgets work? Well, if it's a big enough thing, then maybe yes, and kind of with pneumococcal. The Ministry of Finance in the UK was really behind this and they kind of understood it and they realized, no, we'll just know, we can just borrow to do this. But you're right that normally the way bureaucracies work is I'm the group that has got, you know, X million dollars to spend this year on this particular thing. And my budget is capped over many years. And so I don't, I don't want to put money aside for something that might not happen. So, you know, part of it is, yes, it makes things complicated. I think the solution is you sort of have to get people at a higher level who understand that this is worth it and kind of say, yeah, we'll just, guys, we'll just increase your budget if this hits because it's worth it. And part of it is kind of working through some of these details. Like when we got so close to doing an AMC for malaria way back, way, way back. And actually Larry Summers figured out a way to put it in the tax code and it was in the Clinton budget, which then never passed. I can't remember exactly which year it was. It would have happened. So you put sufficiently clever people and they figured out, figure out a way to make it work in the government structure. So it is, is, Yes. I have spent many, many hours talking to bureaucrats about the challenges of how do they make this work. And some of the solutions are, well, I'm just going to put some of my budget every year into a fund and it'll just accumulate. I don't think that's the most efficient thing. That's sometimes the only way that they're going to do it. But it's part of the challenge of what we're doing is to make they, to work through these mechanisms again. We did it with pneumococcal. It's possible to do it, governments did it, but we want to work through it again because these things do come up.
- [82:18]
David Roodman
Yeah, yeah.
- [82:18]
James Snowden
But there's billions of gain on the table. It's worth figuring out the financing mechanism.
- [82:24]
Imran Rasul
Right, right.
- [82:25]
David Roodman
I'm actually curious to go back to the case of the malaria vaccine. So what is the basic story? It sounds like, like something like the AMC was designed and then people got on board and it was literally just the failure of not getting the budget through.
- [82:46]
James Snowden
So the basic story is, so Michael Kramer, my husband, was working on different ways to promote innovation and then got into the neglected tropical diseases as an important case study. And, and we worked together on designing something for doing the work of what the benefits were and of accelerating again. It wasn't that you come out with a malaria vaccine, it was that you would accelerate getting a malaria vaccine. We did malaria, HIV and tuberculosis. We actually wrote a book on how you would design this called Strong Medicine. And it went through a lot of the details of how you would design it. There was a expert working group that was set up with center for Global Development, and that was the one that ended up saying, well, let's start with pneumococcal. But we'd been hoping that it would be a far off challenge rather than a kind of near case challenge. But the idea is, well, let's try it out with pneumococcal. If it works, we'll then go on to, you know, malaria or something. And it worked, but kind of things had moved on and we never got to the malaria vaccine. I mean, we were arguing for it to be malaria or HIV from the beginning, but it was kind of, look, we haven't done one of these before. Okay, let's do something and get, get away. Win, get a win. And of course, there were companies who thought that they were close on the pneumococcal, so they were lobbying that it should be pneumococcal. Interestingly and annoyingly, the pharmaceutical companies were all saying, oh, we're not putting much resources into malaria vaccine. Not because we couldn't make money from it. No, God forbid we would be, you know, know, influenced by money or returns or anything. We're not evil people. We, we would work on it if it was, you know, if it was scientifically possible. But it's not science. You know, we, it's too hard a science problem.
- [85:01]
David Roodman
Wow.
- [85:02]
James Snowden
And I can see why they do that for PR purposes. But like, no, you are meant to take into account your shareholder value. Of course you shouldn't be working on something. Of course you wouldn't be working on something that wouldn't make you money. And of course, if there was a malaria vaccine, there would be huge pressure on you to keep the price down. This was in an era when there was huge pressure on people to keep the price of HIV drugs down, which saved a lot of lives. But also taught pharmaceutical companies, for God's sake, don't invent anything that's useful for poor people because you will have your price driven down. In a sense, it was the right thing to do for hiv, but it had these negative consequences. Consequences. And our response to this and remember we were doing this in the midst of all of this HIV battle and we were saying, great, I'm glad that HIV drugs are getting out to people, but you are sending a terrible signal to pharmaceutical companies about how to do innovation for diseases of relevance to low income countries. Can we please do this other thing that combines an incentive and gets it out at low price to people? You don't have to have this 01 argument about patents or not patents, which again we saw in Covid that's just the wrong argument to be having. We can have both. We can have the incentive for innovation, we can reward the innovation and charge a low price and get it out to people. I just, sorry to be so passionate, but yeah, if we had had a malaria vaccine earlier, like so many people's lives would be so different.
- [86:45]
David Roodman
Yeah. And I think, I mean, passion is the appropriate reaction.
- [86:52]
Interviewer (Rob Wiblin or host)
Karen Levy on when governments should pay for programs instead of NGOs.
- [86:59]
Rob Wiblin
To some degree we've already talked about this, but a lot of people might have the reaction like the Kenyan government should be funding this. It's like, it's weird that a nonprofit is involved in coordinating this kind of thing. I guess it seems like there was a test where that disappeared for a year and the program stopped. It wasn't as if the government stepped up and paid for it. And I guess there's probably quite complicated, interesting decision making, institutional reasons why it is the case that it's not easy to grab a few million dollars and a bunch of stuff to take over the role that you were doing. If you walk away, then the program freezes.
- [87:28]
Karen Levy
Kenya is a resource constrained place. Right. And so again, I mean, this may sound glib, but it's kind of like saying like, well, if poor people just spent more money on stuff, they would be less poor, they're poorer because they're poor. Right. And so, you know, there are enormous pressures. There are lots of needs that resource allocators within the Kenyan government need to fill. Right. Countries like Kenya borrow a lot of money. Right. So it's not, I think it's an overly simplistic mental model to kind of say, well, there's this big pile of money, okay? It's, you know, the government, they're so rich, why don't they Just spend money on this. If you think about those funds as like taxpayer funds, we're convinced that like the people receiving the deworming drugs shouldn't pay for them. Well, but that's their government, that they
- [88:21]
Rob Wiblin
would be paying 4% of the taxes effectively.
- [88:23]
Karen Levy
Yeah, exactly. Okay. And so look, this can be taken to extremes, right? And of course there are things that governments can and should pay for. But in some ways I almost feel like the amount of effort that it would take to ensure that these funds were allocated and dispersed and delivered and used well, year after year is frankly,
- [88:46]
Rob Wiblin
you know, it's easier to.
- [88:49]
Karen Levy
We should do that for Kenya. Like, we should just do that for Kenya. Okay. And you know, there are other countries like South Africa that pay for it themselves. You know, India is paying for most of it themselves. It's leveraged by a much smaller amount of money that pays for the technical assistance and support around those basic costs. It's a similar thing. It's not like, you know, blaming poor people for being poor. You know, Kenya is resource constrained, right. There's a lot of things they need to spread their resources over. And if this is something that can be easily taken care of by philanthropic funds, like, I would much rather see that happen. And hopefully, you know, again, there will be a time not that far from now where Kenya won't need to have a deworming program.
- [89:42]
Interviewer (Rob Wiblin or host)
Open philanthropy lead Alexander Berger on declining returns in global health and finding and funding the most cost effective interventions.
- [89:52]
Rob Wiblin
It seems like if distributing bed nets is something like 10 times as good as just giving people the equivalent amount of cash, shouldn't you then be able to get leverage on top of that by lobbying governments to allocate more aid funding to malaria prevention, including distributing bed nets or doing scientific research into malaria vaccine, which I guess it seems like there's a pretty good candidate that's come out recently that might really help us get rid of malaria completely. Why don't those kind of in addition help you get further leverage and have even more extra impact?
- [90:19]
Open Philanthropy representative (possibly Alexander Berger)
I mean, you sort of see the issue with infinite regress, right? It's like, well, why can't you go one layer more meta than that and advocate for people too? And so I think the answer is that a, in a weird way, the problems in the world actually just will not support giving at that scale in a super cost effective way. So I think this is kind of an interesting point that I wish effective altruists would pay a little bit more attention to. I don't feel like I haven't done A good job articulating it. So it's not like something that people should necessarily. I understand. But I think the giveaway top charities actually set a very, very, very high bar in terms of spending at large, large scale. And so one way to put it would be like the Institute for Health Metrics and Evaluation at the University of Washington. They compiled the Global Burden of Disease report. They try to say how many life years are lost to every cause of death around the world every year. And they estimate that there's something like two and a half billion DALYs lost to all causes every year. Year. And I think givewell, this is off top of my head, so I could be wrong, But I think GiveWell thinks they can save a disability adjusted life year for something like $50. And so if you were trying to spend just a billion dollars a year, which is like 3% of the NIH budget, less than 0.3% of US philanthropic dollars every year on stuff that's as cost effective as that, then you would need to be reducing total global life years lost from all causes everywhere by just under 1%. And I think that if you sit with that number that's just really, really high, amongst other things, it just shows that if you were trying to do that at 100 times bigger scale, you literally couldn't because you would have already solved all health problems. And so I don't know where the curve is of declining marginal returns, but I would guess it sets in pretty steeply before even 10 times bigger than that. And so I think people sometimes underestimate the size of the opportunities when they think about like, oh, we can make a leveraged play that could be 10 times better. And it's like maybe an individual donor could but open Phil that we'll need to eventually be giving away like a billion dollars a year, maybe more. That is actually not the relevant benchmark for us. We're giving it a scale where it has to be able to absorb more resources. South Asian air quality I think is a really interesting example where you know this, but your listeners might not. We have these three criteria that we use for picking causes, importance, tractability and neglectedness. And in importance, I think this is sort of a crazy case. So I mentioned earlier IHME who produces the Global Burnout Disease Report report. They estimate that almost 3% of all life years lost to all causes globally are lost due to air pollution in India. And that's a mix of indoor smoke from cooking and outdoor air pollution from burning coal, from cars, from burning fuel crops, and in some Ways I think it's appropriate when you hear numbers like that to be skeptical and to say, should I really believe these? And you have to rely on some social science to get figures like that. You can't really run randomized control trials where, where you expose people to a lifetime of air pollution, thankfully. And so, as with all social science literatures, I think there's some reasonable concern or question of is the magnitude that we're getting. Right. But I don't think it's going to make you want to downweight that by a lot. Maybe it's a factor of two or something. And so you're starting from such a high base that the importance just ends up being continuing to be huge. And then on the neglectedness criteria, it gets a really small amount of philanthropy right now. So the best report we've seen on this, I think estimated something like, like $7 million a year of funding for air quality work in India. And that's just like, for something that's causing so much of all of the health problems in the world, that's like a trivial, trivial fraction. And a lot of those funders are actually motivated by climate and climate will get you some of the benefits that you care about in air pollution, but they can come apart. And so I think there's a lot more to be done there. The last criteria, honestly, is the weak point on this one, where tractability is a challenge for the funding in India as a foreign foundation is hard and frankly getting harder. And air pollution has a bunch of different causes and there's sort of no one silver bullet policy that's like, okay, if you could just get the legislature to pass this, then you would be okay. But a bunch of things from sort of trying to encourage modern stove usage to getting coal power plants to adopt these units that remove small particulate matter from the air, to changing emission standards for new vehicles all seem like they would have a reasonable shot at this. And so, so if we did something like quadruple the funding in the field, we would only need that to reduce air pollution in India by something like 1% relative to the counterfactual in order for that to be more cost effective than the GiveWell top charities. And I really don't think that's trivial. I think that's actually a hard high bar, but I think it's probably doable.
- [94:45]
Interviewer (Rob Wiblin or host)
GiveWell researcher James Snowden are making funding decisions with tricky moral weights.
- [94:53]
Paul Niehaus
It turns out which charities you think are most cost effective are just extremely sensitive to what your moral weights are on different kinds of good.
- [94:59]
Rob Wiblin
So yeah, let's talk about some of these moral weights as opposed to empirical weights. How do you go about estimating the value of these different benefits and harms?
- [95:08]
Paul Niehaus
So I think there's a question, there's like a really high level question about whose values should we be using to make our best guesses? So one, you might think the beneficiaries of the values which care about about. Secondly, maybe our staff are the best people to be making this decision. Thirdly, our donors or fourthly, maybe some idealized consensus of all people or what do other major prioritization organizations, how do the World Health Organization make this trade off, that kind of thing. And so I think at the moment we do it for our own staff. But trying to take into account these various other data points, we have asked our donors, we've surveyed a few of our donors and generally got the impression that most people just don't have numbers in mind mind, which is just consistent with my understanding of how people think. It's like not many people are walking around with this figure in their mind of how they would value preventing a death compared to increasing somebody's consumption. This is not true for some of our donors, some of our really engaged donors. I'd really encourage them to go to our spreadsheet and just input their own values and see how that changes the answer. I think it's quite unlikely that we'll end up investing a lot in trying to elicit our donors weights because we just don't think most people have a good answer. We have invested quite a lot in trying to understand how other organizations make these decisions. And so there's a few different ways you can think about this. The World Health Organization has these thresholds for what they consider a highly cost effective intervention in terms of dollars per dali. So anything which is more than three times GDP per capita per disability adjusted life year is not a cost effective use of money in that country. And anything which is between 1 and 2 would be considered pretty cost effective. There's another question about what does that actually mean pretty cost effective versus not cost effective. And I'm not entirely sure how well whether those thresholds are really used in practice because it just depends on your budget, I guess. So that's kind of one input. You can also look at stated preference surveys or revealed preference surveys. So there's a very famous study, I forget the name now, but it looked at different occupations and tried to come to an estimate of how much people were willing to pay to avoid a micromort. So a Very small chance of being death. And you could use that to think about how to trade off consumption against survival. Against survival. Yeah. And so one big problem we've seen is a lot of this literature is based on developed countries. And so that's why we're doing this work with iDInsight to go into an area of Kenya where we think the people there are quite likely to be. They're relatively similar to our typical beneficiaries, although that's obviously still a huge generalization. And so iDInsight are going in there and asking them questions about how they would make these trade offs. And we hope that, that that might be useful in us thinking about, well, what do the people we're trying to help actually value? I think kind of one problem with this is it's pretty hard to ask most people these questions and particularly to try and get people thinking in a pretty consequentialist or utilitarian mindset. So I think that's something that's likely to be quite challenging. So we'll see how that goes.
- [98:05]
Rob Wiblin
So just to make it more concrete, you're weighing up things like increasing someone's income, income versus the risk of them dying versus the risk of maybe their child dying versus perhaps like direct suffering from disease. Those are the kind of things that you're weighing up and trying to say, well, 10 of this is worth 2 of that.
- [98:26]
Paul Niehaus
Yeah, that's right. So one of the most controversial ones would be what's the value of preventing a death at a particular age relative to preventing the death at another age. And so this is quite interesting because I think, I think the global health community generally has a way of thinking about this, which is a disability adjusted life year or the quality adjusted life year. We actually, we don't use that anymore as a kind of baseline for our own moral weights. And the reasoning for that is that it turned out that a lot of our staff actually value preventing the death of an adult more than they value preventing the death of a very young child. So we stopped using that and now we all have our own kind of ethical ways of our own ethical systems that we use to prioritize lives of different ages. And I can kind of speak to my own one, which is very briefly based on the time relative interest account, which is ethical theory by Geoff McMonn. And I think this allowed me. So Andreas Morgensen has a really nice paper on his website where he kind of formalizes this. And the basic idea is that there are maybe two things that are bad about dying or there are lots of things that are bad about dying, but one is to kind of how many years of life that you lose and the other is kind of how much interest you have in those future years of life. And so this I think helps account for my intuition that I don't feel particularly strongly but that preventing the death of a very, very newborn child might actually not be so much more valuable than preventing the death of an adult. So you take the kind of number of expected years of life left and you multiply it by this kind of pretty subjective factor which basically accounts for. Does this person have cognitive function? Can they make plans? Are they like a functioning agent in the world. World? And you multiply those two things together to get something that looks kind of roughly. You end up with a roughly log normal distribution over age. So the death of a very young child is something I would value relatively less than. And I think my peak value is the death of an 8 year old I think is where I end up. But other people have really different.
- [100:20]
Rob Wiblin
That's when it's the worst for them to die.
- [100:22]
Paul Niehaus
That's when it's the worst on my values. Yes.
- [100:24]
Rob Wiblin
Another kind of controversial moral issue that you guys will encounter is suicide versus involuntary death. Have you discussed that a whole lot because you were supporting the anti pesticide suicide group?
- [100:37]
Paul Niehaus
Yeah. So this is probably the most controversial of any of our moral weights.
- [100:41]
Rob Wiblin
Yeah, I know this issue is controversial with my friends whenever it comes up.
- [100:45]
Paul Niehaus
Yeah, it is. It's really something that sparks people and I think fairly. It's a very difficult thing to talk about, I think neutrally. So I think maybe if I give a bit of background about the organization that we ended up making a grant to and that'll maybe give bit of perspective on which we can kind of think about this kind of moral question. So we made a grant of about $1.3 million to the center for Pesticide Suicide Prevention. And I won't go through the full evidence base, but basically the idea is that they're going to go into India and Nepal and work out which pesticides people are using to attempt suicide and what the case fatality of those different pesticides are. So for context as well, we think that about 800,000 people a year die from suicide and. And somewhere between 100,000 and 300,000 of them are through pesticide. The data is that bad that it's quite hard to narrow down closer than that. So this is kind of very common method of suicide, particularly in agricultural communities in developing countries and particularly in South Asia and Southeast Asia. So basically the mechanism here, there's two possible mechanisms. So one is that you're making a common and lethal form of suicide more difficult to access and that might reduce the amount that people have this kind of very easily available method of suicide in front of them them. And then the other method is the other possible mechanism and we're not really sure which of these is more likely. The other possible mechanism is people are still attempting suicide, but they're doing it with less toxic pesticides or pesticides which are less likely to kill them. And so they generally, they'll have a higher chance of getting through that period and then hopefully go on to make a full recovery. So I think there's a big thorny argument here about how valuable it is to prevent suicide because you, you're not treating these people, you're not treating them for mental health disorders, you're essentially just preventing them dying. And so I think this is an interesting one because two of our staff actually place zero weight on preventing a suicide through means restriction. I think there is a decent argument there. A lot of it kind of depends on what your definition is of a life worth living. And I'm not sure anyone has a really good answer to that. But there is also a lot of empirical information which is relevant. So I think this kind of highlights the nature of these conversations, which is like a lot of times it's just going to be dominated by your ethical view. But other times it really does seem like, you know, there's actually evidence we can go out into the world and like, find out which should change our mind.
- [103:02]
Interviewer (Rob Wiblin or host)
Lucia Coulter on the hits based approach to funding global health and development projects.
- [103:08]
Rob Wiblin
I asked for audience questions for this interview and we got a very cheeky one from a previous guest of the show, James Snowden, who used to work at GiveWell and now works at Openfield Philanthropy. He actually declined to fund you guys, I think back in 2020 or 2021 when he was working at GiveWell, but I think he's given you a grant more recently. Working at Open philanthropy, he asked. GiveWell declined to fund you when you were first starting out, but more recently you've gotten this Open Philanthropy grant. Why was that and what do you think they missed?
- [103:37]
Lucia Coulter
Thanks, James. Yeah, so when GiveWell were first looking into lead as an area, they were prioritizing their time and using quite broad heuristics like how confident can they be in paint as an important source of exposure or where can absorb a lot of funding soon. And at the time they weren't convinced and they didn't have a CEA that they felt confident in, but they kind of planned to come back and look at it more. And then James moved to Open Phil and lead kind of moved with him as an area. And now open philanthropy is thinking about the lead space more holistically and is excited about leap. I did ask you him what had changed. I think he mentioned that he'd updated on the health and mortality effects with the new evidence and also that he'd previously underestimated how tractable the work would be and also how many countries we would be able to get to. I think he said he was partly skeptical about our relative inexperience in the field and also our track record, but that he'd now kind of endorse a less conservative attitude towards that.
- [104:41]
Rob Wiblin
Yeah, a concern that I've had about kind of the give well mindset, which is looking for opportunities to do good where you can really demonstrate that they're having impact and you can kind of repeat the same thing again and again. That's been shown to work in the past. Worry that I've had kind of from the beginning is just that it could push people against systematic solutions with very high level solutions where the effect isn't that predictable, but the impact when you succeed might just be really enormous. And this is kind of a common critique or a common concern of the giveaway mindset that they're very well aware of. And I think actually that they've been trying to resolve by funding more things like LEAP over the years. But if you think about the UK didn't solve waterborne diseases by putting chlorine dispensers in each house. It solved it by having government build enormous sewage systems and enormous piping systems that brought clean water to everyone sort of simultaneously. And there might just be no real alternative to having governments at a massive level do the things that kind of only governments can do or that only city governments can do at least. And likewise here, we didn't solve the problem of people getting exposed to lead in the air through leaded gasoline by giving people face masks or telling them to change their behaviour. We just said, no, we're getting rid of it, it's gone, we're banning it. And I guess you're doing something that's a bit of a hybrid model where you've got this replicable model where you can kind of demonstrate that this worked in Malawi, it's probably going to work in these future countries the same way. But you're leveraging the power of the state to Just kind of fix problems somewhat by force, saying, look, we're not just not doing leaded paint anymore and if you do this, we're going to send you to prison. Ultimately, that's where this will end. So no more leaded paint, please. But I do worry that the fact that GiveWell didn't fund this, I think maybe does show a weakness in the research methodology or it shows that it's not going to be able to identify, or at least that the mindset most strictly applied is not always going to be able to identify really amazing high expected value in interventions, because just things that are extremely high expected value will often have too much uncertainty, too much that's unmeasurable about what they're going to do. Do you have any reaction to that?
- [106:44]
Lucia Coulter
Yeah, I think that sounds right. I think it's just much harder to identify interventions like that, like health policy, regulatory interventions. It's much harder to identify with that level of certainty the expected impact. And maybe GiveWell is not best place to be doing that with their methodology, or maybe it's something that they could kind of expand their scope into. But there's been very little of that type of thing that they've looked into or recommended, especially now that James has left. I think that was kind of something that James was very interested in.
- [107:16]
Rob Wiblin
Yeah. So I might get some of this wrong, but I think so. GiveWell has paid attention to this critique and has been open to funding more of these things. We talked about that with Ellie Hasenfeld earlier in the year, I think. So James Snowden has gone to open philanthropy, which has a bit more of this high risk, high return, I think they call it hit space giving mindset, where they're going to make 100 grants thinking that one of them is going to hit it out of the park and pay for the entire portfolio. And he's maybe taking more of that approach on the global health and wellbeing side at open philanthropy. So this is maybe exactly in his wheelhouse now. I guess if there's any entrepreneurs out there who are thinking of starting charities to focus on issues in the developing world, it would not surprise me if the highest impact opportunities are exactly the kind of thing that you're doing. It's improving policy in neglected areas where you can just have an enormous impact by getting the policy settings right, by getting government to take responsibility for things that government ought to be taking responsibility for. You're nodding your head. Same intuition.
- [108:08]
Lucia Coulter
That sounds right. Yeah.
- [108:13]
Interviewer (Rob Wiblin or host)
Rachel Glenister on whether it's better to fix problems in education with Small scale interventions, interventions or systemic reforms.
- [108:23]
David Roodman
So it seems plausible that focusing on specific interventions is meaningfully worse than encouraging governments to make systemic reforms to their education systems. Is that something that you worry about?
- [108:34]
James Snowden
So it's certainly the case that there are big picture systemic issues that cause problems in education. Like it's a big, big deal. So we were talking about the benefits of teaching at the right level and the fact that curricula is sometimes very overly ambitious and that's a problem and it'd be great if people fix that problem. And there's a lot of RCT evidence that basically individual programs that kind of help you get round that fact, like teaching at the right level are really beneficial. And you might think, well, the right thing to do is well, let's go fix the underlying problem. And I'm all for that, but it's hard and there's all sorts of political economy reasons why things are designed for the top of the class. And so if you can do that, great. If you can get an education system to respond to the needs of low income income children, that's more flexible, that's evidence based great on you. But I'm not going to wait for that to do the other things. Because let's be clear, every single thing that we're recommending here has been tested in isolation and worked in isolation. So it is not the case, it's empirically not the case that you need systems reform to do these things. Things, they have been tested and they have proved to work when they were the only thing that was done. Because a lot of these come from RCTs, not all of them, but a lot of them do. And RCTs are exactly, that's what they do. They just move one thing, they don't move everything else. So systems change is important. Having systems that actually care about low income kids is really important. But you can't just magic that. You can't put in that as a recommendation care about lowering him. And there's a political economy of that. It is true that there's probably some benefits of doing a bunch of things. There may be benefits of doing some things together if you had better. The structured pedagogy is an example of that. They actually tie together a whole bunch of things that move together. But you don't, don't wait till you have the perfect get on with doing the things that you can do.
- [111:10]
Interviewer (Rob Wiblin or host)
GiveDirectly co founder Paul Niehaus on why it's so important to give aid recipients a choice in how they spend their money.
- [111:19]
David Roodman
So I guess the key theme here seems to be givedirectly just values kind of recipient choice super highly. My sense is that one of the core values of GiveDirectly is giving the recipients of charitable efforts a choice around how they use donated resources. Yeah. Is that right? And if so, why does that seem so important?
- [111:39]
Paul Niehaus
That's right. And there are two reasons. One is instrumental, which is that we often think that actually people who are there on the ground living their own life are going to have more insight and more perspective on how to use money than we as outsiders would. Not always, but often. So the housing, the metal roofs, I think are a good example of that for me personally, where I have a PhD in Development Economics. And so I think, you know, I feel comfortable saying that as far as expertise goes and what to do about poverty, I'm as well trained as anybody. I never would have guessed that so many people wanted to replace their thatch roof with a metal roof. And when we saw so many people doing that and looked into it to try to understand why they were doing that, you learn interesting things like if you have a thatch roof, you have to replace it or repair it every so often. And that costs money. And if you have a metal roof, it lasts longer and so you save that money and so it ends up looking like a pretty good investment. Investment, a long term investment to build a metal roof. Or you can use a metal roof to collect clean drinking water from the rainwater and you don't have to travel a long way to a lake or a river and you're less likely to get sick from things that are in the groundwater, things like that. So that's all stuff that was complete news to me as an outsider, but completely obvious to the people living on the ground. So I think it's partly in order to be able to tap into that local information. But I do also think this may vary a little bit, I think depending on the donor. I personally put a lot of of value in people's ability to make choices per se. I'd say that in sort of my description of an ethically good world would be one in which a lot of people have more autonomy and more self determination than they do now. Even if they do sometimes make mistakes or use it in ways that I disagree with to some extent. I put a lot of intrinsic value in that.
- [113:15]
David Roodman
Let's talk about the empirical evidence a bit more. So unconditional cash transfers have been studied empirically many times in a range of context. Context as you've noted. Yeah. Can you summarize what we know about the return on investment recipients get?
- [113:29]
Paul Niehaus
There are certainly cases you can pick out where a large share of the money got invested in some sort of asset and business got better. And the return on capital in that business was maybe 20% per year or 30% or even up to 50%. So there are certainly cases like that where in a sort of very narrow financial sense we can say, well, we've learned from this that people have access to high return investments investments and it's great that we're able to finance them. But I would actually push back a little bit. I think about that instinct of trying to kind of put everything into one number because I think once you get into the reality of how diverse life is, it's too complicated for that.
- [114:01]
David Roodman
Yeah, it must be frustrating that. Well, it seems like there are all these randomized controlled trials on a bunch of interventions like this, including unconditional cash transfers. And many of them in some ways have it easy. They're tracking the effect of bed nets on malaria and it's pretty easy to measure malaria, at least relative to how difficult it seems to be to measure how do people spend money when there are dozens, hundreds in some sense an infinite number of potential options for them. And how do you measure the benefit they get from that?
- [114:37]
Paul Niehaus
And there are all these sort of knock on things like, you know, you see impacts on mental health or recently there have been papers that found reductions in in rates of suicide or rates of all cause mortality. And so you also think about that. Is that a separate thing that I need to value separately or is that the result of all these other things that I was just talking about? So I think it's really, really hard. And actually I think that the way economists have traditionally thought about it, which to me makes more sense, is to say we're actually going to think of this as like the numeraire, right. The value to giving someone a dollar is a dollar and then we're going to use that as a reference point in a comparison to other things and say, well, relative to that, that how great is a bednet or deworming or any of these other things we want to think about.
- [115:15]
David Roodman
Yeah, I see. And at least part of the thinking behind givedirectly is like in surprisingly many cases the value of giving someone something that you've decided in advance might be best for them that costs a dollar might actually be less than a dollar because people have such different needs and it's hard for us living in other countries to predict them.
- [115:34]
Paul Niehaus
That's the thing we want to watch out for. And the issue there is that in the sort of aid or philanthropic system system, there isn't any built in feedback loop that prevents us from doing that. So think about it. By comparison to a commercial business, if I'm trying to sell something for a dollar and people value it at less than a dollar, nobody buys it. And I learn quickly this isn't working. I don't have product market fit. In the philanthropic world, if it costs you a dollar to produce something and people value it at less than a dollar, they're going to say, oh, thank you, this is better than nothing. And so you don't get that feedback loop of people telling you, hey, there's something better that you could have done on with your money. So we have to be very intentional about building that in.
- [116:13]
Interviewer (Rob Wiblin or host)
Sarah used to scuthrie on whether more charities should scale back or shut down and aligning incentives with beneficiaries.
- [116:23]
David Roodman
It strikes me that charities seem to scale back or shut down at potentially like a much lower rate than like businesses, businesses. And that seems, that seems bad. It seems like businesses have some incentives that don't always lead to incredible outcomes, but they are probably tracking something like whether they provide value. And if charities aren't shutting down nearly as often, that might suggest something about too many existing that aren't providing much value. Does that seem true to you?
- [116:54]
Sarah Eustace Guthrie
So I think you're pointing to the most important factor here, which is that structurally charities are built in such a way that your expectation on priors would be that a lot of them would just be doing stuff that's not very useful. Because the difference is that the way a business works is, you know, at least in an ideal case, a business provides a product or a service to their consumers. If that product or service isn't very good, then unless there's monopoly or something wonky going on, consumers stop purchasing that product and you know, that business goes out of business. But what happens is that instead of it being dual when it comes to charities, it's actually this triangle. So on one point you have the charity, on one point you have its beneficiaries, but then on another point you have the donor. And in some ways the donor ends up having most of the power. In some ways, because if the donor is the one that's giving the money to make make this program happen and you're the charity and you're looking there at your beneficiaries and you're looking there at your donor and you're saying if the donor doesn't like what we're doing, the program can't happen. But if the beneficiaries don't like what's going on, as long as the donor keeps liking this, this can keep happening. And to be clear, I'm not saying that, you know, charity founders are sitting there saying, I'm going to do bad things for my beneficiaries. I think, you know, know nearly all charity founders are really well intentioned and are trying to make the world better. But you end up in this structural space where you are structurally incentivized to make your donors as happy as possible. And then you're only really incentivized to make sure you're helping the beneficiaries insofar as the donor cares about it. And so maybe the donor, you know, wants to see photos of happy seeming beneficiaries. Maybe they want to see studies of this program is really effective. Maybe they want to see ongoing monitoring and evaluation data. But depending on what they demand, things could look very different on the ground. And of course, organizations can also demand these things. But in general, I think funders are often the ones who have the most leverage.
- [119:05]
David Roodman
Yeah. So it seems like one solution is, is focusing more on outcomes for beneficiaries and really trying to figure out some incentive structure. That means that the actual thing that you're measuring and holding yourself accountable as an organization is beneficiaries getting the thing that you think is valuable for them and that they hopefully say is valuable for them. But there's been this huge backlash against the Randomista movement, which tries to kind of forefront outcomes. So conducting randomized control trials to kind of better measure the actual impacts of global action and global health and development programs. And I guess, yeah, you pointed out in the article that you co wrote with Ben, which is an asterisk and which we'll link to that there's this kind of new move toward what's called trust based philanthropy, which is a term I actually hadn't heard before. But yeah. Can you talk about what trust based philanthropy is and I guess maybe what the best case for it is?
- [120:02]
Sarah Eustace Guthrie
Absolutely. So trust based philanthropy is one of the biggest forces in philanthropy right now. Like if you go, if you go to a conference on philanthropy, people will use trust based philanthropy language. It's gotten a lot of acclaim and I think it's very much in the philanthropy water in a way that I did not fully understand until I both started, like talking to some donors and also doing some research on this. And so trust Based philanthropy burst into wider awareness, awareness in the US around some of the racial justice protests a couple years ago. And it's very much rooted in this idea of we need to equalize the balance of power between donors and nonprofits and the communities they served. And it points to this really important thing, which is that it seems wrong for donors to have a disproportionate amount of power. And if they're trying to improve things in the communities that they serve, that's only going to happen when there's this partnership of equals among donors and nonprofits and their beneficiaries. And so what does that actually mean in practice? Well, that's a trillion dollar question. And I will say I get the sense that in practice, sometimes this just means using different words to describe the same thing happening as it was before. But a lot of the shift that you see in practice is, is about reducing these burdensome reporting requirements that charities have to do for their donors. And so the fact of the matter is that a lot of donors, especially if it's money from like government development agencies rather than from private donors, they'll require this ridiculously long list of reporting requirements. So they want you to report on, like, this is exactly how we use the budget and this is like exactly what we did for this program. And obviously, maybe you're listening and you're thinking, oh, that makes sense. But somehow many organizations manage to do this in the most aggravating and time consuming possible way. So I remember talking to another charity about a big grant that they'd gotten and they said, yeah, maybe you should apply for this grant. But just heads up, we had to hire a part time operational person for a full year solely to do the reporting requirements for this one grant.
- [122:22]
David Roodman
Wow.
- [122:23]
Sarah Eustace Guthrie
Because they would make them fill out all these forms and if you didn't do it in exactly the right way, they would take away your money. And so like, reporting requirements are like a huge headache for a lot of nonprofits. And I think this is actually like less known in many effective altruist charities because actually many like EA donors actually operate in a way that's very much like the trust based philanthropy approach, which I suppose I haven't even gotten to, which is just saying, hey, maybe we should make these reporting requirements less onerous. And I, I fully endorse many aspects of that because I think there's a lot of ridiculous time that's spent on reporting that like, ultimately just makes the funders feel better, like, oh, we're doing our due diligence to get you to it in this detailed way. But really, for years, nonprofits have been saying, oh my gosh, can you just make this easier for me? But maybe not even saying that to donors because they're afraid to say that to donors because they then maybe the donors will take away their money. So lessening reporting requirements is a big part of this. And some donors have gone very far in that direction. So Mackenzie Scott has become one of the biggest philanthropists in the world. And I don't even think many people are aware of the full extent of her grant making. But over the last four years, she has given, I think, more than $17 billion to nonprofits profits. Probably that number will be outdated by the time that you release this podcast because she's just dispersing ginormous amounts of money and she doesn't have a huge staff. I don't know actually how many staff she has. But if you would do that under the normal reporting requirements, you would require the world's most ginormous foundation. But what she's done is she has been giving this money out with absolutely zero strings attached, at least to my knowledge. And often she doesn't even talk to the nonprofits ahead of time. So she'll like. I mean, I don't know how this actually works, right? But I think it's something along the lines of like the head of the Boys and Girls Club in Boston gets an email and says, hey, Mackenzie Scott wants to give you a million dollars, no strings attached. It'll be in your bank account next Tuesday.
- [124:26]
James Snowden
Right.
- [124:26]
Sarah Eustace Guthrie
And so in some ways this is a big win because charities have to spend less time on these reporting requirements. They have to spend less time, you know, trying to figure out, out exactly what does this donor want from me cultivating these relationships. But I also have worries about this because I think in some ways this approach conflates the nonprofits with the beneficiaries themselves. Right? Because trust based philanthropy in some ways boils down to trusting nonprofits to do what's best for the beneficiaries. And I think, think that you can think that people who run nonprofits are like, really well intentioned and great and you should be friendly and make their lives easier. But also think like, hey, maybe it's better for everyone involved if we have some ways of making sure that that money is actually helping the beneficiaries lead better lives.
- [125:22]
David Roodman
Yeah, it does sound really nice in theory. What is your best guess at how to, how to solve this? Like how to, how to give power to beneficiaries in Particular.
- [125:36]
Sarah Eustace Guthrie
Right. So I don't have a five point plan to fix philanthropy.
- [125:39]
David Roodman
Yeah, yeah, yeah. It's a tall order.
- [125:41]
Sarah Eustace Guthrie
But I do think there's a couple ways of going about this. So first of all, if you're really focused on, I just want to empower beneficiaries as much as possible. Like if that's your biggest priority, I think the best thing you can do is direct cash transfer. And I think that organizations like GiveDirectly, they've set it up in a way that, you know, mostly gets rid of concerns about corruption that makes sure it's going to folks who are the neediest around the world. And I think I am eagerly waiting for the moment in which people who are really focused on empowering beneficiaries start adopting cash as one really promising approach. Because I think it's such an exciting approach. Approach. Like when I think about like ways to empower beneficiaries, it's like one approach is like, oh, well, maybe they're on a committee that helps decide where some of these charities funds go on and they have these long discussions and it's like, okay, that seems like, maybe vaguely useful, but it also seems really easy for that to end up in a failure mode where it doesn't actually make that much of a difference. And on the other hand, if you just send people money, like they can do whatever they want with that money. And a lot of studies have shown that people in, in extreme poverty tend to really reliably use that money on stuff that's meaningfully improves their lives. But if I think that if you care about how can we empower people to do what they want to improve their own lives, then just giving it to them directly and bypassing the nonprofits entirely, not to put myself out of a job, but like, that is maybe just the simplest, best possible way. Give them the money directly.
- [127:16]
David Roodman
Yeah, yeah. I mean, I'm a huge fan of GiveDirectly and of course of that intervention. I guess you've kind of pointed at one of the potential ramifications which is putting a bunch of charities out of the job. And I guess, do you. Yeah. Do you have an image for how this happens? Like if you actually kind of follow this to the logical conclusion, you probably see a bunch of charities shut down and what does that actually look like that doesn't feel horrible to a bunch of bunch of people actually at charities working and hoping to do good work.
- [127:52]
Sarah Eustace Guthrie
I think in my ideal world there would be a lot more money that's directly going to Cash. And what that means is not that, like, everyone who works at a charity is out of a job, but that instead they can be working on the interventions that are, like, most impactful to help improve those people's lives. And so I think in my world, what that looks like is not like, oh, there are zero charities. I mean, unless we're living in our, like, ideal act, ideal world. Right. But that, that there's charities that have different focus areas and that maybe have a different approach to monitoring and evaluation. And I think that that's a really exciting future for both beneficiaries and the people at working. Working at charities because, you know, like 99.9% of people who are working at charities are there because they want to help people. So to me, this idea of we can help more people better, like that is in fact a win win. I think that reframing it from shutting down to shifting program focus areas or shifting people from one program to another program is a really helpful way of thinking about this. And I think one interesting example for this is New Incentives, which provides conditional cash transfers to help incentivize immunizations. And you may have heard of New Incentives because right now, now it's doing really well. It's one of GiveWell's top charities. It's widely recommended. But what you might not know is that when New Incentives originally started, they were doing a very different program. So their founder was really excited about conditional cash transfers to help reduce poverty. And she was originally focused on, I think it was cash transfers to prevent mother to child HIV transmission. And so she was working in Nigeria and they were working in a bunch of clients clinics, and it was going decently, but they realized, oh, actually things look different than we'd originally thought and we're really not going to be able to scale up with this program. And so, you know, they'd been operating for a couple years, it had been going kind of well, and I think they faced this fork in the road. I mean, I wasn't involved at all. But my sense is they face this fork in the road of should we keep going with this program that we think is decent or should we try to pivot to something else? And I can imagine them, you know, sitting in the room trying to figure out like, wow, this is a really tough decision. We have a lot of staff who might be affected, what's going to happen. And what they ended up saying is, look, we are here to make a cost effective, impactful charity and we want to focus on the most useful thing. So they ended up pivoting. They pivoted to these cash transfers for immunization. They ran an rct. It turned out out really well. And then they massively scaled. So they went from like a small number of employees. So I think they now have more than 3,000 employees in Nigeria.
- [130:34]
David Roodman
Holy crap.
- [130:35]
Karen Levy
I did not know that.
- [130:35]
Sarah Eustace Guthrie
And so pivoting is what allowed them to unlock their potential as an organization. And so I think that, like, this is a lot about how we frame this conversation. Are we framing this as more people should do the painful and unpleasant thing of shutting down, or do we frame this as more people should look at the exciting opportunities of pivoting their programs to things that can help more people?
- [130:59]
David Roodman
If you want to learn more about Sarah's lessons learned, I highly recommend the Asterisk article she co authored with Ben, why we Shut Down. It's so, so good. And there are also some juicy, some juicy quotes from people in the field who refuse to even be named because they were so controversial. So it's just a really, really good read.
- [131:23]
Interviewer (Rob Wiblin or host)
James to Bendarana on why we need loads better data to harness the power of AI to eradicate malaria.
- [131:31]
James Tebendana
Malaria is heterogeneous. The distribution especially now, as I said, we've seen the last 20 years, the last two decades of success and so we've sort of of controlled the malaria that is not embedded within the context. And now we're having to deal with, you know, malaria that is context specific, localized, and has variables that are making it more difficult for you to achieve the continued decline. And then we have hard to reach areas or you even have behavioral elements. As I mentioned, treatment seeking in the private sector. You've got to be able to reach the private sector. You're not going to suddenly change and say people should all go into the public sector because they made a choice, they want to go into private sector. So what are you going to do about the private sector? And then we've talked about hard to reach areas and malaria is a disease of poverty. You may say that there are health facilities, but there are households that are not able to access services because of either geographical distance or the fact that the health facility may be open at a time when they should be looking after their livelihoods or looking after their gardens and they won't have that time. So there's some of these barriers that are preventing access and having the capacity to understand those nuances within the context. And that requires data.
- [133:02]
Rob Wiblin
Data.
- [133:03]
James Tebendana
It's not insurmountable. It's just that you have to have the right data. You need to have the data in terms of the people, you need to have data in terms of the mosquitoes, something called entomological surveillance. And you need to understand whether the parasite is continuing to be susceptible to the drugs or that the parasite itself, when you test for it using a malaria rapid diagnostic test, you are likely to be identifying it. Because even now we have what is called HPR2 deletions, where the malaria parasite is now deleting a gene that the rapid diagnostic test.
- [133:38]
Rob Wiblin
Oh, wow.
- [133:39]
James Tebendana
Supposed to pick.
- [133:40]
Rob Wiblin
That's savvy. Okay. And that's because I suppose there's selective pressure on not being detected, because then you won't. I see. Because then you can spread better.
- [133:48]
James Tebendana
Yes.
- [133:48]
Rob Wiblin
So you.
- [133:49]
James Tebendana
Selective pressure. So just having that information that allows you to then make the right choices and really deploy the tools in the right location, the right intensity. I mean, we've scaled up everywhere, but we still have gaps. But then you might find a situation where there is something going on and you need to either react with a better net, for example, a pyrethroid PBO net, or you may have to react with more intense community case management, for example, integrated community case management, because you may have seen an upsurge starting and you really want to make sure it's kept down. Okay. Or you have a situation where there is genuinely a upsurge taking place and you really want to stop that happening, because the sooner you stop it down, the less likely you are for mosquitoes to be able to transmit.
- [134:37]
Open Philanthropy representative (possibly Alexander Berger)
Yeah.
- [134:37]
Rob Wiblin
I guess we got into this topic because you were saying that this work where you're tracking where is malaria taking off and using that information in order to shape your strategy, that could be incredibly useful. But it's maybe harder to convince donors to support, or at least. At least donors who are focused on proven interventions to support it, because it's harder to say ahead of time, exactly what is the cost effective for this? Because it's not just a matter of delivering the same treatment to other people in areas with the same malaria prevalence. It could be that it's incredibly useful some year, or it could be that some year it doesn't really help your strategy all that much. It's a bit more of a speculative spend. Yes, it is.
- [135:09]
James Tebendana
But from a personal viewpoint, and I think from an organizational viewpoint, surveillance and response is a critical intervention if we are to achieve malaria elimination. We already see that in Asia, where surveillance and response is playing a very important role in continuing to identify the last case of malaria where it is and to make sure it's dealt with. But we've not seen that, you know, the kind of investment in surveillance and response in the control setting where you have higher transmission intensities. Because, because I think the numbers are so large and in some ways the trends or the spikes get lost out by the noise. But if one was to say, if you had additional funding, where would you spend it? I think surveillance and response for me is one area that can have potential if done properly. Having the right data, data and using it. Because you need to have data and then you need to be able to use it at the subnational level, districts, provinces, and then at the national level. Looking ahead, it will be difficult to use machine learning, it will be difficult to use AI without having data. And if in the next decade one is to envisage machine learning as contributing to some of the decisions, some of the predictions that allow us to be really more savvy at our choices, we are going to need this data. And if we don't start collecting that data now, when we have the tools to use the data, what will we be doing? Because you need this long term data and you need consistent quality that can allow you to then get into decision support tools and to really optimize your decision making. I tell my team at the moment we are making decisions, right? We are bringing on board modeling to help with some of our decision making. So all the cost effectiveness modeling, some of the modeling work that allows you to identify where to put particular interventions and combinations of interventions. I think in the next 10 years we should be looking to things like machine learning to be able to support that decision making so that we're probably more precise and we're more targeted and that's going to require data.
- [137:36]
Rob Wiblin
Kind of surprised me that machine learning or AI would be, it seems like the decisions would be things like malaria is more prevalent here or malaria is increasing in prevalence here, so we need to invest more money in that particular location. Do we need something as sophisticated as machine learning to make these decisions? Or is that going to add a lot of value beyond what a human decision maker can do?
- [137:54]
James Tebendana
It will add value, especially as the data elements increase. Because as I've stressed, you do have the parasite, the vector and human behavior. So looking at the mosquito data, the breeding sites, the breeding habits, the human biting elements, there are situations where the malaria mosquito is changing its habits. So rather than biting at night, some mosquitoes are starting to bite earlier in the evening or later in the morning. Bringing that data together, the parasite data, what's happening in terms of Some of the genomics, some of the changes that are taking place and then really the trend data, bringing those data elements together more comprehensively to allow us not only to anticipate what's happening now, but also to anticipate what's coming forward forward. Climate change. Climate variability is going to affect malaria and the climate variables. You know, the variability is going to increase and become more complex. And as we bring that data in. Right. For seasonal malaria chemo prevention, for example, we are constantly monitoring the start of the rainy season, the duration of the rainy season. In some of our locations we've had to change from four cycles, that is four treatments, treatments one month apart to five treatments because the season of malaria transmission with rain is getting a bit longer and there will be some situations where some locations where it is shorter. All right. Because of, as I said, climate variability. And so you're bringing in climate data as well. So these data elements I think will give us the opportunity to be a bit more precise in some of the choices that we make. But some of the transitions. Can you switch from indoor residual spraying to nets? Can you switch from seasonal malaria chemo prevention to integrated community case management? What are the switches that we need to be making as it's coming down? So we continue to maintain a cost effective approach, but we continue to sustain the downward trend of malaria until we have those game changers, whether it's gene drive, whether it's the transmission blocking vaccine, in which case the decision making would probably be simplified.
- [140:10]
Rob Wiblin
Yeah, that makes a ton of sense.
- [140:15]
Interviewer (Rob Wiblin or host)
Lucia Coulter on rapidly scaling a light touch intervention to more countries.
- [140:21]
Rob Wiblin
Let's talk about the lead exposure elimination project. We'll get to more recent events later, but can you start by telling us this amazing story of some of the very first things that you did? What did LEAP set out to attempt in Malab, Malawi?
- [140:33]
Lucia Coulter
We were helping the Malawi Bureau of Standards, supporting them with testing capacity, updating their regulation to make it more enforceable and making sure that like the right samples were being collected need to be kind of coloured paints because they're much more likely to be, to be leaded than white paints. And the default kind of globally for anyone doing kind of monitoring of a paint industry would be to just collect white paints. So you'd naturally miss lead in that. So that's a bit of a process. And then then industry typically is unlikely to reformulate until they feel that there will be consequences.
- [141:07]
Rob Wiblin
Did you call them up and say,
- [141:08]
Lucia Coulter
yeah, I mean we spoke to them before we did the study and we said, are you aware of lead as an issue in paint and that sort of thing broadly. They said that they were aware of it but that maybe some other manufacturers were doing it, but not them. So then we come back with the results and we say there is a lot of lead in your paint. And they're like, oh, okay. And at that point we offer our support. So we can help in quite a few ways. We can give, we have a paint technologist who's absolutely amazing, who can give really detailed technical support with the switch. We can help them find suppliers of the non lead raw materials which can sometimes be a barrier because their usual suppliers might not necessarily supply these non lead alternatives. We also offer to retest their paints for them so they can be confident that their lead free and that sort of thing. So some of them engaged, some of them didn't really. Some of them said to us like, I don't really know, does Malawi standards really have testing capacity? Do we really have to do this? And so we were like, wow, that's
- [142:06]
Rob Wiblin
ballsy to be saying, okay, sure, you busted us, but we don't think that you have the testing capacity to check again officially.
- [142:13]
Lucia Coulter
Yeah, exactly.
- [142:13]
Rob Wiblin
Interesting. Were any of them mortified? Sounds like.
- [142:19]
Lucia Coulter
No, not that was apparent to me. I mean, I don't know how they were feeling internally. In a professional context you might not really like let on your real feelings about it. Yeah, I think that from the perspective of a manufacturer, they're only putting in a small amount of lead. 1% intuitively doesn't feel like that much. Right.
- [142:38]
Rob Wiblin
It's just a splash of lead.
- [142:39]
Rachel Glenister
Yeah, just a little bit.
- [142:40]
Lucia Coulter
It's just a tad. So yeah, so I think it's not intuitive like how bad that could be. Like one way of communicating it is that if you had like a little sugar sachet, you know the type that you would get at a cafe to put in your coffee, if that was filled with lead dust and you sprinkled it across an area the size of an American football field, that level of lead loading would be sufficient to cause lead poisoning if a child spent time in that environment.
- [143:08]
Rob Wiblin
I see.
- [143:08]
Lucia Coulter
So a very, very small amount of lead can have these really toxic effects. And that's not intuitive. That's pretty surprising. So I think that's probably how people think about it. But often manufacturers in, in some of our experience will move really quickly. Like sometimes days after we show them the results, they've ordered their non led alternative ingredients.
- [143:27]
Rob Wiblin
What's happened since then? What sort of countries have you expanded to and what sort of experiences have you Been having there.
- [143:33]
Lucia Coulter
Yeah. So since then we have expanded to 17 countries. So most of them are in Africa. Zimbabwe, Madagascar, Sierra Leone, Niger, a number of others, and then a few outside of Africa as well. Pakistan, Bolivia, Uzbekistan. And basically we prioritize countries based on what expected burden of lead poisoning from paint. Obviously it's pretty difficult to estimate. Also on neglectedness. So are there any other actors doing anything there? And also on how. On tractability, the classic basically int. Kind of.
- [144:09]
Rob Wiblin
Yeah, I've heard of it. What goes into the calculation? Trying to figure out the burden of leaded paint.
- [144:17]
Lucia Coulter
So a big part is population size. So if it's a big country, it's more likely that there's more lead poisoning from paint. Anything we know about the size of the paint market, use of paint in the country? Anything we know about whether there's likely to be a lot of lead paint on the market?
- [144:32]
Rob Wiblin
Do some countries use more paint than others? Are some countries big on paint and others are not?
- [144:36]
Lucia Coulter
Yeah, in some countries, a lot of the population live in rural areas where there's just not much painting going going on. Usually less economically developed countries.
- [144:45]
Rob Wiblin
I see.
- [144:45]
Lucia Coulter
But in those countries there might be very rapid paint market growth, so they might actually be quite important.
- [144:50]
Rob Wiblin
Yeah. So I guess you want to ideally get a country right before an explosion of urbanization or construction.
- [144:55]
Lucia Coulter
Yeah, exactly.
- [144:56]
Rob Wiblin
So where are you at in the different countries? I mean, if you've gone from you did one country three years ago, now you're operating in 17. Yeah, it's a big increase. Have you been hiring kind of hand over fist?
- [145:08]
Lucia Coulter
I mean, our team is nine, so it's a small team. I think it kind of highlights the fact that it's a relatively light touch, intervention. It's really the civil servants in government that are doing most of the work and we're there to support, we're there to help them overcome whatever barriers come up. So where are we at in the various countries? So in all of them we've now established good collaborative relationships with the relevant government authority. In 11 of them we've completed paint study, and in eight of them we have commitments from the relevant government authority to either introduce regulation or to start implementing regulation if it already exists. And in four of the countries we already have reports that paint manufacturers representing over half of the market share have started switching to lead free.
- [145:54]
Rob Wiblin
Yeah. Has the responsiveness of the government been at the same level as in Malawi? Has anywhere dragged their feet?
- [146:01]
Lucia Coulter
Not really. I think when we first started leap, we were expecting a big part of our role to be Advocacy to be convincing governments that this is an important issue. But that hasn't really been the case. There's sometimes a lack of awareness to begin with and then we can communicate about the problem and do the paint study to bring that awareness. But the barriers, then they're convinced they're on board. Obviously no one wants lead paint in their country. So the barriers are more about the relevant part of government having limited capacity, limited time.
- [146:31]
Rob Wiblin
Yeah, I would have thought that that would be an issue, that you'd contact someone and say, sorry, I'm busy, my hands are full. I agree with you, but I can't act on this. Does anyone say I don't have a budget to deal with it just I don't have budget to do the testing or I don't feel like I have the authority to act.
- [146:43]
Lucia Coulter
Yeah, so the budget thing comes up a lot and that's where we can help. So we'll offer support with funding the paint study and actually we often do the study in collaboration with the government partner and then we offer support with funding for multi stakeholder meetings. That's often a big step to getting progress on an issue is the kind of lead government authority will need to get other parts of government involved and they'll need to engage industry and bring them along. So they need to have all these meetings and sometimes it's to agree on draft laws and that sort of thing. And so we can help provide funding for the meetings and then we can also help with the testing capacity to some extent. So we can help with accessing international testing or improving their internal capacity. And then we can also do a lot of the industry outreach side of it as well. So if we can offer all of that, then the budgetary constraints are usually not a problem.
- [147:36]
Rob Wiblin
I see. Is it an issue that many of these countries, they presumably don't have great testing for lead, they maybe don't have the best scientific facilities to handle this.
- [147:45]
Lucia Coulter
Yeah, I think probably most low middle income countries don't have existing ability to test for lead in things. The approved method is using a lab based technique. The machine costs 30 to $50,000. And then there's also consumables, there's also training that's needed. So that can be something that limits their ability to enforce a regulation.
- [148:13]
Rob Wiblin
But you were saying, I think you were testing samples for $15 or something overseas. Why don't they just mail them out to our lab overseas? It sounds like it costs peanuts.
- [148:23]
Lucia Coulter
Yeah, so that's a good option and it's something that we help get set up and we kind of provide training on how to prepare the samples so that they can be sent abroad. And we'll even cover the costs of the international analysis for a period of time. Time while they're getting set up. It's a very kind of cost effective option. But I think a lot of regulatory authorities would ideally like to have their own capacity.
- [148:49]
Rob Wiblin
Okay.
- [148:49]
Lucia Coulter
Yeah.
- [148:50]
Rob Wiblin
Just as a kind of matter of principle that they don't like stuff that comes from outside. They feel a bit embarrassed maybe that they're having to ship this to another country.
- [148:57]
Lucia Coulter
I think it's been mentioned before that sometimes they don't really like the idea of sending money abroad. Why can't we do this in our own country or locally? I think also. So if you're a regulatory authority whose job is to run a lab and test for things, it's quite nice to just be able to do that and not have to rely on external.
- [149:18]
Rob Wiblin
I see. Yeah. It could be more convenient to just be able to send it to the basement of the people in the basement rather than mail it overseas. From a logistical point of view.
- [149:24]
Lucia Coulter
Yeah. And mailing paint can be a bit tricky. Sometimes you can't actually ship wet paint because it's flammable. So you have to prepare dry samples. But then sometimes mailing companies, companies think that you can't ship dry samples. So it's a little bit inconvenient, but it's pretty easy overall.
- [149:41]
Rob Wiblin
I guess maybe one reason that leaded paint is still an issue is that it's usually produced locally. Right. It's this kind of commodity business where it's an extremely heavy item that's sold at relatively low cost and it's also relatively low tech. So most countries are producing their own paint or even most cities kind of have their own paint supplier. And the fact that it's kind of at that medium scale means that it hasn't been possible to just identify. Identify a handful of places in the world where paint is being produced and tell them to stop. You have to go kind of city by city, country by country.
- [150:08]
Lucia Coulter
Yeah, exactly. Yeah. In the vast majority of the countries that we work in, the vast majority of the market is locally produced paint.
- [150:15]
Rob Wiblin
Yeah, yeah. How big a deal is it that you offer? This was a paint technician or paint formula specialist. I have to say that is one of my favorite examples of a super high impact career that I don't think anyone would ever have guessed that you should go into paint formulation. And then this is going to allow you to save the lives of thousands, tens of thousands of children, but that's how it's turned out. What's the guy's name again?
- [150:36]
Lucia Coulter
He's called Phil. Phil Green. Yeah. He's amazing.
- [150:38]
Rob Wiblin
How important is that to the paint companies? Is it often an impediment to them that they just don't know how to make yellow paint or red paint without his help?
- [150:46]
Lucia Coulter
Yeah, so it depends on the paint company. Some have internal chemists that are really experienced with formulation, but others don't. And it's not actually a simple thing. It's not like you just, just. It's not like one for one replacement. It's more like baking a cake where if you substitute an ingredient, you kind of have to adjust other things to make sure it has all the right properties. So having someone who has a lot of experience with both different types of formulations, but also the local context and what suppliers are available and what raw materials you can actually get, where and how that could work and how reliable all the different raw material suppliers are, is just absolutely amazing. So I think that's, yeah, very high impact career.
- [151:23]
Rob Wiblin
I guess in as much as the companies are reluctant to push forward when they, after they speak to Phil, they can kind of be persuaded that maybe this isn't going to be as much of a pain in the ass as they were expecting.
- [151:34]
Lucia Coulter
Yeah, yeah, exactly.
- [151:35]
Rob Wiblin
It sounds like this has all been suspiciously smooth. You're going to go in, you find out there's a lead in the paint, you call out the government, the government mostly follows up, you hassle them a little bit, You, I don't know, pay for them to have some meetings, pay for them to run some more tests. What part of the whole process here takes the most person time or the most money? Is there any stage that is kind of a hassle for you?
- [151:58]
Lucia Coulter
Yeah, I think the bit that takes the most time is the part between getting the government on board, establishing that relationship, doing the paint study, identifying that there's a lot of lead in paint, but then actually getting regulation in place. And that's just because it's a complex process. It varies by country and involves a lot of different steps. Complicating factors can come up. And also the civil servants that we're working with are juggling a lot of plates. And so that can, can just. That can take a long period of time. And our approach is just to try and be in really close contact, lots of calls, emails, WhatsApp messages, visits, to just make sure that we are as responsive as possible to whatever part of that process that we can help with. And that varies a lot by country, but that kind of period takes up a lot of time, basically.
- [152:48]
Interviewer (Rob Wiblin or host)
Karen Levy, I'm one why pre policy plans are so great at aligning perspectives.
- [152:55]
Rob Wiblin
I know one methodological innovation that you're excited about at the moment are pre policy plans, which I actually hadn't heard of these until you mentioned them.
- [153:03]
James Snowden
Yeah.
- [153:03]
Rob Wiblin
Could you explain for the audience what they are?
- [153:05]
Karen Levy
Yeah. So the idea of a pre policy plan is inspired by a pre analysis plan, which we know is common, but even becoming more common and more typical in social sciences. And this idea came up when I was doing some work with an organization in Botswana called Young Love. Now, Young Love is led by Noam Angrist and Mojsepi Mac Chang, an incredible team of people that they lead in Botswana. And several years ago, they were replicating a study that had been done in Kenya many years earlier, earlier by Pascaline Dupas that provided relative risk information to adolescents in order to help them make better decisions about their sexual partners and reduce their vulnerability to HIV infection. And the idea being that, you know, traditionally the options given to adolescent girls are, you know, have sex and die or be abstinent. I mean, these are not realistic choices for people. Okay. And, you know, I think the real brilliance behind Pascaline's study was empowering girls with information that allowed them to manage risk and explaining to them that older men are riskier and more likely to be HIV positive. And so by choosing to have relationships with younger partners, they could reduce their risk of hiv. And so that was the intervention.
- [154:40]
Rob Wiblin
And I guess they decided to test it again, I guess in this new context of this new era. And it's just as well that they did.
- [154:45]
Alexander Berger
Yeah.
- [154:46]
Karen Levy
Do you want to explain why exactly? Now, of course, while the test was happening, we had no idea if it was going to work or not. And the Young Love team had done a really extraordinary job in developing relationships with government partners.
- [155:03]
Sarah Eustace Guthrie
Right.
- [155:03]
Karen Levy
They were doing, doing this program in schools. They had gotten the Ministry of Education all excited about it. And ironically, you often worry that if you find evidence that something works, no one's going to take it up and run with it. But there's also the converse problem, which is if you find something doesn't work, you don't want people to scale it up. Right. And so in discussing this dynamic before the results of the study came out, we decided to work with the government partners to put together what we called a pre policy plan. And so the idea was to game out in advance, what will we do if the results are X? What Will we do if the results are y? And the reason that we did that is, you know, when you're thinking about a hypothetical future, it's very easy to, to assume that you're gonna be rational, that you're gonna follow the evidence. But the reality is, when you're standing there later and you've got some data, there is this enormous temptation if it didn't work, to say, oh, but it would have worked if it had just been different, or vice versa. Right. And so it was creating a space in the which there was nothing on the line and everyone could really think about, in theory, what they would do.
- [156:27]
Rachel Glenister
Right.
- [156:28]
Karen Levy
And so when you create an environment where everyone cares about evidence and we want to be evidence driven, it's very easy to get people to say, well, of course we won't scale this up if it doesn't work. And of course we will scale it up if it does.
- [156:42]
Rob Wiblin
Yeah.
- [156:42]
Karen Levy
And then, sure enough, you know, when the results came in and they were, you know, very, very sadly disappointing, it was much easier to connect people to that mindset that they had been in beforehand. You know, people really liked the program, they wanted it to work. You know, it was an incredibly charismatic group of people doing this. And so everyone's first reaction was, oh, but let's do it anyway. Okay. But when we looked back at that pre policy plan, it really helps people. Exactly, exactly. I think that the other thing that's really useful and important about a pre policy planning process, it's a wonderful tool for aligning the research and policymaker perspectives.
- [157:32]
Shruti Rajakapalan
Right.
- [157:33]
Karen Levy
Very often there's not enough communication up front, and what this can lead to is, you know, evidence not being useful because it's not available on time, for example, or, you know, the results are not applicable to a population that policymakers are actually needing to make policy for. And so a pre policy plan, the idea is to get people to sit down in advance and say, and really line up what are the questions we're asking? What are the outcomes we're measuring? When are we going to have have this evidence alongside what decisions are being made as policymakers? What choices do they actually have? When and how are resources getting allocated? Right. So that researchers can make their work relevant and responsive to the actual choices policymakers are making, and vice versa in
- [158:27]
Rob Wiblin
terms of pre policy plans, which I guess is figuring out under what conditions would you want to scale it up? Under what conditions would you hold steady? Under what conditions would you cancel a program ahead of time before you get biased by what the results you're getting? Actually are. It seems like in this case the results were very clear cut and quite devastating. It's interesting to me that even in this case people kind of wanted to push on. It's so hard to let go of a program that even when the most likely outcome seems to be that you're causing harm, it's possible that this doing this, having this conversation ahead of time might have made the difference between continuing the program and not.
- [159:01]
Karen Levy
Yeah, I mean, I think the truth is that like most people want to do something, right. And I can relate to that. Like I am action biased, right. So all else equal, I'd rather do something than nothing. Right. And so I understand where it comes from. Right. And you know, in this case, I think, you know, as you say, it was very clear cut, but often it's not right. And so the other thing that a pre policy plan can do is force some tough conversations about, well, how much impact is enough to make this worth doing right, or what if it's effective for some subpopulation but not for another. These are all questions that are much easier to really think through and interrogate when you don't know the answer. Right. And I think there's a lot more that we can do in the global health and development development space to be thinking about how we would use new information before we get it.
- [160:05]
Interviewer (Rob Wiblin or host)
Rachel Glenister on the value we get from doing the right RCTs. Well,
- [160:11]
Rob Wiblin
earlier this year I spoke with Eva Vervout about generalizability of RCTs. And she had this kind of archetypal stylized fact that at least in her sample, the typical result differs from the average effect found in similar studies so far by about 100%, which is to say, say that if all existing studies of an education program find that it improves test scores by 0.5 standard deviations, the next result in her sample was as likely to be negative or greater than one standard deviation as it is to be between zero and one standard deviations. I guess you think that Eva is potentially overstating the implications that this has and how dire the situation is for external validity of RCTs. What's your general perspective on this?
- [160:47]
Imran Rasul
Yeah, so I think it's really important to distinguish the different causes of why a different study might have a different result because we take away different conclusions, we act differently depending on the reason for why a different study might have a different result. So one reason why a second study might have a different result is the problem didn't exist there. So then I'm not at all surprised that you have a different finding in another study. It doesn't worry me at all. The second reason why you might have a different effect in the second study is it's implemented less well. In the first study had 80% take up and the second study had 20% take up. So again, you don't want to just compare the results of the two studies. You would then want to adjust for take up in those contexts. And the third reason is that just people behave really differently in different contexts. And that's. That in a sense is the assumption behind saying this is, you know, a problem. And I guess my reading of the evidence is that actually most of the variation between studies that we see is either they're actually implementing a completely different kind of program and we don't have enough studies, so we bundle a whole bunch of things that are completely different together and then it's no wonder we get different results or the implementation was really different and bad or really good. And that just tells us, well, we need to really work on implementation. It might tell us really important things about. This is a really hard thing to implement. And that's a really useful lesson. It's not really about generalizability. Generalizability for me means people act differently when they've faced the same problem and
- [162:36]
James Snowden
they're given the same incentives, but they
- [162:39]
Imran Rasul
respond to those incentives really differently. And my reading of the RCT evidence is that actually we get surprisingly similar
- [162:46]
James Snowden
results, if anything, across different studies.
- [162:49]
Imran Rasul
So I think the way we should think about this is we have very few studies that test exactly the same thing in lots of different contexts. We have quite a lot of studies is that are testing some fundamental underlying principle about human behavior. The trick is then to take that fundamental principle about human behavior, which we've tested many times and now know to be true, and think about how to implement that in the local context. And that could be about, you know, offering lentils in one context and you know, ice cream in another.
- [163:27]
James Snowden
Right.
- [163:27]
Imran Rasul
It's. But those things don't need to be tested by RCTs.
- [163:31]
James Snowden
Right.
- [163:31]
Imran Rasul
Some of that is about it is knowing your context. But it's just, it's basic logistics. And some of the basic logistics we do need to test every single time. But we don't test with an rct. You test with good monitoring processes. So it's like saying, I know there have been enough studies that I know if I hang a bed net it will work. I'm not going to test that again. I'm going to test do they hang them up here, did they hang them up?
- [164:00]
Dean Spears
Right.
- [164:02]
Rob Wiblin
Which is probably a lot easier to test.
- [164:04]
Imran Rasul
Much, much easier to test. So it's doing that causal pathway and saying which bits are making sure that you've analyzed the problem.
- [164:14]
Dean Spears
Right.
- [164:15]
Imran Rasul
That they actually have malaria. The next step is if you get that people have tested is if you give malaria bed nets for free. You know, normally you get higher take up and people are most likely to hang them. But the third thing is how do we make sure that we have a monitoring system that the malaria bed nets actually get out to people and also maybe test occasionally, you know, that they're hanging them up. But that doesn't need an rct. That's good monitoring.
- [164:43]
Rob Wiblin
If you need a lot of trials to kind of establish a stylized fact about how humans behave, behave. How many things have we learned of that kind? It seems like it might be a fairly short list if you need like dozens of studies to figure out that something just occurs like in most cultures, in most countries and most situations. Is there kind of a list of like these things that we've learned, these like underlying principles that we use whenever we develop any program at all?
- [165:02]
Imran Rasul
Well, maybe not every program, but we know that people are very sensitive to price and convenience in the take up of healthcare.
- [165:13]
David Roodman
Right.
- [165:14]
Imran Rasul
So never charge for preventative healthcare. Like that's a pretty big darn policy conclusion.
- [165:21]
James Snowden
But we've got a lot of different
- [165:22]
Imran Rasul
studies that point towards that. So in the health field there are a number around this, you know, price and convenience type of things. And then in education I think we've learned this more general lesson from many, many studies that it's really about, it's not about the inputs, is about the teaching, how people teach. And the biggest problem in most developing countries is that the teaching is way above the heads of most of the kids. So they're on grade two, you're teaching them at grade six. That's a pretty fundamental thing which we've got a lot of progress that's going to come into a lot of different education programs to use that principle. People respond to incentives, the price goes
- [166:09]
Rob Wiblin
up, people buy less.
- [166:10]
Imran Rasul
Yeah, so there's quite a lot of, you know, I'm not going to remember all of them off the top of my head to do a plug for my old organization J Pal. The last thing I did before I left was bang heads together of the various academics working in an area. And of course they love to kind of put caveats on everything but say, okay, what are the main cross cutting points principles that have come out of RCTs in your area. So those are called policy and site notices. And you can go to J PAL and under each one they will at least list three, like common cross cutting principles that they found. So in agriculture and in health, in education, in governance. So that will give you a list
- [166:57]
James Snowden
of some of those.
- [166:58]
Imran Rasul
So it's. For most of them it's not more than about three, but they, they are quite general.
- [167:02]
Rob Wiblin
This potentially makes RCTs look like substantially better value if you can come up with these principles that are going to apply to basically every other program in the area and future.
- [167:10]
Imran Rasul
Because I don't want to overdo it. Not every other program, but at least
- [167:14]
Rob Wiblin
something that you might want to consider in most cases.
- [167:16]
Claire Walsh
Yes.
- [167:17]
Rob Wiblin
Because, yeah, I guess sometimes people worry that, oh, each RCT is quite expensive. And then to test all of the programs that we might consider ever running, it's just prohibitively expensive. But if you can find these underlying principles. Sentence of much broader value.
- [167:29]
Imran Rasul
Yeah, so I think that's a point that people really get confused about, which is the more academic and abstract the rct, in some ways, the more policy relevant it is. Which sounds really odd and counterintuitive. But the point is an RCT that tries to test one of these fundamental principles of human behavior, behavior is actually much more useful because if you're just testing a package of things and you can't really tell an underlying principle from it, you're testing whether these six things together have an effect, you can't take that to another context. You can't learn as much from it as if you go in deliberately saying, okay, my question is not does this work? But are people price sensitive in this area? Do people use something more if they pay for it? Like, I'm testing this more general principle that's more generalizable and it's better value for money.
- [168:28]
Rob Wiblin
So there's like a lot of different potential sources of heterogeneity, like differences in culture or like differences in the quality of implementation or the fact that a program was different in some ways that aren't really getting picked up in this meta analysis. And also just like random noise, of course. Do you think that any of these is underrated as how significant it is or how much like variable variability it creates?
- [168:45]
Imran Rasul
So I think implementation quality is something that people don't take into account enough, but that varies by the kind of program.
- [168:55]
James Tebendana
Right.
- [168:55]
Imran Rasul
I think what we ought to be doing is looking if someone's taking a deworming pill, there's not that much difference in the Quality of the pill, usually, right. The quality is very easy to measure in that. Did someone take. Take it?
- [169:10]
James Snowden
Right.
- [169:11]
Imran Rasul
But if you're talking about a training or, you know, graduation program, then it really matters. So I think we should be looking at, you know, when we do these meta analyses, using our theory to say, is this something where the quality is going to matter, quality of implementation is going to matter, or is it not?
- [169:30]
Rob Wiblin
Do you think we potentially deliver too many programs where the quality of implementation matters? Like, I guess that can potentially reduce the expected value quite a lot just because there's a high chance you're going to screw it up.
- [169:38]
Imran Rasul
So I'm a big fan of, in general, unless you've got a really good evidence against this, of doing less complicated programs, fewer components, and just doing one thing well massively. Like, I think that's a huge problem that we try lots and lots and lots of different things. And I don't mean test lots of things because we want to test lots of things to find the one really good cost effective thing and then we should scale that up massively and we don't do that enough.
- [170:14]
Interviewer (Rob Wiblin or host)
Economist Mushtaq Khan on really drilling down into why context matters for development work.
- [170:22]
Rachel Glenister
You find that actually a policy that worked very well in one country is disastrous in another country country. And different countries which have successfully developed have done so with quite different policies. And that's a puzzle. But the puzzle becomes much more explicable when you look at this interaction that actually the policies that work, the institutions that work, the rules that work, depend on the capabilities, interests and power of the players and how they implement and follow those policies. Because no policy can be enforced on people who don't want to follow. So actually the idea that policy is a black box, that the government just announces and everyone starts following it, is a total mistake. A government is just one organization amongst many organizations in society. And there is an interplay going on between governments, political parties, opposition, trade unions, churches, mosques, the people, different kinds of agencies and firms. All of them are trying to influence this policy outcome. But also, and this is critical, implementing it on a daily basis. And if the vast majority of your organizations and society are happily violating the rules and not checking each other, then it's not going to be an implementable policy. And we always make this mistake that we think that enforcement always comes from above, that there is some kind of political police or some kind of enforcement agency sitting and watching everyone. And if you violate rules, they come down on you. What we often Forget is that 99% or at least 90% of enforcement is happening without that. What we call the vertical enforcement, it is happening through horizontal enforcement by peers at different levels of society. So when we mean powerful, we mean the relevant people at that level of activity who are as powerful as the people violating. Who is powerful depends on the policy being discussed. For some policies, the powerful are people in a village. For other policies, the powerful are people who are big firms. But whoever is violating the rule needs to be checked by other people who are just as powerful as they are. So what we are looking for always are these incremental processes where whatever policy you're looking at, whichever level of society you're looking for rifts between the players, between the powerful at that level, and seeing if some of them might not in their own interest, support developmental outcomes in a rule following way. And we promote that. And if you look at the history of how development happened in advanced countries and how rule of law emerged, it was always through these incremental processes where people at different levels of society, in their own interests started to follow rules and impose rules on their peers. And that horizontal process is for some strange reason not adequately examined by economists and institutional economists. We are often much more concerned about these vertical enforcement strategies which then typically fail. So I think a lot of what I'm saying could be read by people in different ways. And I think that. Let me boil it down to some very basic things which might focus people's minds. I think now it's a kind of commonplace in development policy. People will say context matters. One size doesn't fit all. Everyone will say these things, from the World bank down to the FCDO down to Oxfam. Everyone will say this. So the real question is, is ask yourself, how does context matter? What am I supposed to do about this? Now someone has told me, context matters. What is it about it that matters? And here is where I think all that I'm talking about has a direct relevance. Context matters in this way, that you have a set of plans and policies or you're supporting some activities which you think will support human development. And to me, that inevitably involves looking at capabilities, organizations, et cetera. Do you think these policies will be implemented? Do you think they can be enforced? This is where context matters. So context matters primarily in the sense that enforcement and implementation vary hugely depending on the interests and capabilities of the players themselves and much less on the enforcement capability of some supra agency, which is like the Prime Minister's office or the cabinet or the police, or the Anti Corruption Commission or anything like that so the basic thing you should do always is look at the people you're working with, their capabilities and then ask them, you know, here is a policy to help them do something better. Will they themselves actually support it? Not what they're saying they will, because everyone will say they will do whatever you ask them to do because they want the money. But actually from their past behavior and their activities, do I think this is something that they will actually be able to implement, enforce, monitor each other as peers, report back and do? The basic capabilities of policy implementation at a higher level exist to monitor and enforce this, this and if not, you have several options. You can redesign the policy so you have a greater confidence it works. You can say actually policies won't work here because there's some networked problem here which is so integrated that I can't break it. Then you have to think out of the box of some exit strategy which meets the requirements of your anti poverty or whatever that you're trying to achieve. Or you have to go back, back one step before and say can I build those capabilities directly? Can I work with people to actually build those capabilities which I'm assuming exists with my policy, but I shouldn't assume and maybe I need a policy that is one or two steps behind in terms of its sequencing. So I think there are ways in which all of this makes a lot of practical sense as a sense check when you are asking yourself will this work here? And then then of course you can refer to the work that I do and others do and it's all available, it's free access online and you can read some of the stuff on the SOAS ACE website or the work of Danny Rodriguez or North Wallace Weingast or Ache, Muglu, Johnson and Robinson and all the people we have discussed. Not all of it, but those bits of it which are relevant to the particular policy question that you're addressing. And I think that's the of start starting point. That's the starting point for you as a development practitioner, beginning to refine your questions and getting down to better questions and then answers which you think might make sense there. And then the final step is don't put all your eggs in one basket, experiment with a trial, see how that goes and only scale up once it's working.
- [177:25]
Interviewer (Rob Wiblin or host)
GiveWell co founder Ellie Hassenfeld on contrasting GiveWell's approach with the subjective well being approach of Happier Lives Institute.
- [177:35]
Rob Wiblin
One alternative worldview or general take on how to think about effectively helping people comes from this outfit called the Happier Lives Institute. The distinctive Part of their take is that they want to cash all of the impact of these projects out in terms of subjective well being itself. Self assessed subjective well being. So to compare across charities they use this metric called the wellbe. And one wellbe is the value of raising someone's self assessed subjective well being by one point on a 10 point scale for one year. So if an intervention made me go from rating my life a 5 out of 10 to a 6 out of 10 and that impact lasted for 12 months, then that would be one wellbe that had been generated. So their hope is to evaluate charities on that basis, trying in every case to say how many wellbees are generated per dollar spent. I guess just first off.
- [178:19]
Imran Rasul
Yeah.
- [178:19]
Rob Wiblin
What do you think are the pros and cons of trying to use improvements in subjective wellbeing per dollar as a measure of cost effectiveness? Yeah.
- [178:26]
Alexander Berger
So first I think it would be helpful for me to just explain what GiveWell is doing today, which is we cash everything out either in terms of increased ability to consume, that is people have more money or reductions in disability adjusted life years, some of which are health related and some are mortality related related. But I very much take the point that subjective well being is an important consideration. You know, we don't view the two outcomes we use today as the only outcomes that make sense. They're just the two outcomes that, you know, we've been able to use to date. And I do think over time as we continue to grow and increase the size of our team, we'll be in a position to include more factors explicitly in that analysis. I think the pro of of subjective well being measures is that it's one more angle to use to look at the effectiveness of a program. It's obviously an important one or should say it's obviously, it seems to me it's an important one and I would like us to take it into consideration. And then I think the downside is, or the reasons not to might be on, on one level I think it can just be harder to measure. You know, a death is very straightforward. We know what has happened and the measures of subjective well being are, are squishier in ways that it makes it harder to really know what it is. And then also, you know, I think some people, well, some people might say I really value reducing suffering and therefore I choose subjective well being. I also think other people might say, you know, I think these measures are telling me something that is not part of my sort of view of the good and I don't want to support that and you know, that would cause someone to try and, and would want to leave it out of sort of their calculus and the donations they're making. I think it's some sort of ideal world. I would love for GiveWell to be able to offer options for donors who have different philosophical perspectives about what they want to achieve. Obviously GiveWell institutionally also needs to have a view because there's funds that come to us directly. But ideally, I think in sort of the future vision of GiveWell, you know, for people who have subjective well being as their core focus, other moral values, or maybe even a very different trade off between increasing income and reducing disability adjusted life years, you know, or increasing dallies maybe, depending on how you think about it. Those are programs we'd like to be able to bring to donors and let them choose because we don't see ourselves as being, I don't know, we're not trying to add value by being particularly good philosophically. That's not part of like GiveWell's comparative advantage. And so it'd be better if we could wear donors want it, allow them to use their own judgments to make decisions.
- [180:57]
Rob Wiblin
I think, yeah, to most people it's intuitive that it's more valuable to save the life of someone who feels that they're really flourishing and is super glad to be alive than it is to save the life of someone who thinks their life is barely worth living, who maybe doesn't even care that much whether they live or die. And yeah, it could be useful to use the numbers to make it a bit clearer how this might end up affecting your relative priorities here. If you imagine, imagine people scoring their quality of Life out of 10. That's kind of the standard subjective well being scale. And let's say that we use the number three as the number at which someone is rating their existence as neutral, with kind of the good and bad things in their life canceling out. And that's kind of a typical answer for what people say would be the neutral point for them if they were scoring themselves. So if someone is going to report a quality of life of 4 out of 10 for the rest of their lives, then from a well being adjusted life year, a Wellbe point of view, then it's equally valuable to them to prevent them from dying as it is to increase their well being permanently by one point out of ten, that would be from four to five in this case. On the other hand, if someone reports a quality of life of 5 out of 10, then from a Wellbe point of view, it's twice as valuable to save their life as to increase their well being permanently by one point in this case from 5 to 6 because the difference from 3 to 5 is twice as great as from 5 to 6. So yeah, HLI notes that many people in very poor countries who otherwise might die of malaria in the absence of additional antimalarial bednets have unsurprisingly pretty challenging lives with plenty of hardship in them. And that as I understand it, suggests that to them it's more likely to be cost effective to make people's lives better than to make them longer or less equal. I guess. So that's a very long lead in. But what do you and Giveor make of that sort of line of argument?
- [182:32]
Alexander Berger
I think the place I want to start is I think this is a case where I feel most strongly that I would want to hear from, from the people themselves in low income countries about this topic. And I think that's because I think if you, if you kind of draw out this line of reasoning, it leads you to the conclusion that there is a very high proportion of people living in low income countries who would choose death over continued living based on their self reported life satisfaction. And that's a very uncomfortable conclusion. But maybe more importantly one that is so counterintuitive that I would, I would want to do. I feel the need to like follow up on it before accepting it at face value. And so that may be a somewhat minor point about like sort of where you draw the line on the scale but still, you know, in this case, yeah, I think the sort of maybe purely emotional urge I have is to say that doesn't quite seem like it could be right intellectually. I know it could be right therefore, or I need to follow up on it because it's so inconsistent with my sort of starting point for what people would say.
- [183:40]
Rob Wiblin
Yeah, it definitely can get uncomfortable or weird. Or maybe if you were serving people on the subjective well being and you really said if you score yourself a two, we're going to take it that you actually mean that you would rather not be alive right now, then maybe people would reassess because an interesting thing is that people almost everywhere in the world, when you survey people, even people in serious poverty, almost always say that they think their life is better than not existing and they want to continue surviving and so on. I've heard some philosophers say that that kind of intuition that we all have about how great it is to continue existing might be a little bit suspicious because we might have evolved to have that attitude. We necessarily almost have to evolve to have that attitude even if our lives are very unpleasant. And so that kind of bias might affect all of us. But I'm not really too keen on to go there. And I feel extremely uncomfortable. You know, if someone says that saving their life is really valuable, I'm, I'm glad to take that at face value, what, whatever like, and to trust that over some subjective well being survey.
- [184:35]
Alexander Berger
Right. So, so I mean, just so I think that like that discomfort is a good starting point though, not an ending point. And certainly something that we, we are very committed to internally is, I don't know, one of our company values or whatever you want to call it, is truth seeking. And what we mean by that is we're not to going, going to, we're going to have the hard conversations and keep digging to try to get the answer that that is, you know, correct as far as we can, as we can see it. And so therefore, in this case, I would say I am very suspicious of philosophizing and reaching a conclusion that seems extremely counterintuitive and then running with it. But we're a place that wants to, you know, go deeper and embrace the open to, you know, strange conclusions. Or maybe I should say differently, like conclusions that seem strange to us today, that will not seem strange to us in the future once we've spent more time with them and done more research on them.
- [185:32]
Interviewer (Rob Wiblin or host)
James to Bendarana on whether people actually use antimalarial bed nets for fishing and why that's the wrong thing to focus on.
- [185:41]
Rob Wiblin
So quite a few people in the audience were curious about kind of the, the gap between provision potentially of chemo prevention drugs and provision of nets and actual use. So there's this kind of mainstream concern that you provide nets or you provide drugs for free and then people just don't use them. Or I guess there's this really popular meme that somehow got started that you provide people with nets to protect them from mosquitoes and they use them for fishing, which I think has happened in at least some places, but I suspect is probably substantially overstated because it's a fun story to tell. Yeah. Do you want to comment on that? How do you measure whether things are actually being used and to what degree are they being used?
- [186:20]
James Tebendana
There is a access and use gap for nets and for some of the other interventions. And it's something we pay particular attention to because we would like is to close that gap between access and use because then at least you're maximizing the impact that you get. And, and I think it's important to appreciate that wherever nets are distributed, the majority of the nets are being used. And I think who tracks that information? We track that information. So all the campaigns will have a component of results, measurements that allow us to be able to have a sense in terms of those who have been given the net and those who sort of use the. The net, and those results measurement systems have improved over time. I think the issue with misuse of nets, whether it's fishing, we've got to keep in mind that malaria is a consequence of poverty and malaria can contribute to inequities. And let's appreciate that some of these households are really poor. And even the notion of that they are actually using these nets for, whether it's fishing or over their gardens, is a sign of the poverty that some of these households are experiencing. And I think it is overstated because even in those households, what we know from all the evidence is that the access to nets is an important driver of use. And so by ensuring there is access to, you are actually facilitating the use of. And so, yes, from my perspective, I do hear people talking about phishing, et cetera, but when you go into those communities, majority of people are using those nets. And I think data suggests that the majority of those nets are being used. So sometimes the question is, is it an old net that has been replaced, is it a new net? And I think the fraction of. Of nets that are being misused in that way is probably negligible compared to the nets that are having a positive impact in those communities. And so the question will be, what else is being done in those households that is addressing some of the livelihood issues that they are experiencing, that we know malaria is a consequence, but also. So the level of poverty itself can contribute to malaria.
- [188:52]
Rob Wiblin
Yeah, I think from memory, Against Malaria foundation has some auditing process where they go and check whether the nets are actually being used. And again, from memory, I think the rates of use were over 90%. So it's like, yes, some people don't end up using them for one reason or another, but maybe, possibly they use it for something else. But in terms of measuring the cost effectiveness of what they do, they only do that relative to the nets that are being used, or they only estimate the impact they're going to have based on nets that are actually hung up when they go and check, not based on the number of nets that distributed. One thing that amuses me, I guess, about the meme about fishing is what fraction of all households that are receiving nets are even near a place where they would go fishing or are interested in fishing as a source of food. I think there was one particular case where there was a village that was specifically a fishing village. They all do fishing. That's how they make their livelihood. And they were using the nets for this purpose. But I imagine the great majority of people receiving nets, like fishing is not a key source of income. It's not the way that they're getting food in the first place. So it's hard to believe that this is the first thing that they think of to do, especially if it would involve traveling to somewhere where they can plausibly fish with any meaningful success. It's a meme that frustrates me because I suspect that people are into it in part because it's a clever story. It's like, oh, you thought that the nets would help them, but actually it didn't. So it allows you to one up other people with your level of sophistication and knowledge, even if it's inaccurate. And also I think, because it gives people an excuse for not donating if they can always say, well, it's always the possibility that they'll use it for something else and that it won't actually help, Even though like 90% of the time it does. I'm not sure whether you share my. No, I do share that cynicism.
- [190:20]
James Tebendana
I do. I do share that cynicism because really, it takes away the message from the positive impact that nets have, but also the majority of people who actually use those nets the way they're intended. That for me in itself is also a signal. Signal that is a reminder of the inequities that thrive when malaria is present and that we should be doing more to ensure that. That is access. That is access.
- [190:54]
Interviewer (Rob Wiblin or host)
Karen Levy on working with governments to get big results.
- [190:59]
Rob Wiblin
A common complaint with people who work with governments, I guess, in this context and in all contexts, is a really rapid staff turnover, whereas a program could be turned upside down because the minister changes. Is that a problem that you ran into?
- [191:10]
Karen Levy
Yes. And I think one of the things that I have learned and that I work with partners on now is how do you codify and institutionalize relationships such that they survive turnover. We all know how important it is to have champions, right, in government, but champions leave, right? And so you need to find new champions. And so relationship building is essential and never ends. But you also have to be thinking from the beginning about how do we codify these relationships in a way that is not just an individual thing. And so that can be mous. It can be membership on existing committees or technical working groups, getting written into annual operating plans, seconding people to ministries so that you have people actually sitting there in the office. These are all ways that relationships can be deeper and longer term and more enduring than you would get by. Just like getting one individual person excited, which is a great way to start, but that needs to then lead to some of these other longer lasting approaches.
- [192:30]
Rob Wiblin
Did you ever have to coordinate with people who were in some sense unqualified or maybe out of their depth and so perhaps weren't up to what you were hoping they would do?
- [192:39]
Karen Levy
Well, there were certainly times where I was out of my depth, let me tell you. I think that there is a perception of civil servants or working with governments at, you know, it's slow, it's, you know, nobody cares. And I actually have not found that to be the case. I find that by and large the people that I have met and have worked with in the Kenyan government and in other governments are, they are public servants, they are incredibly dedicated and they are working within really tough constraints. I think, sure, they're gaps in capacity that we all have to face and work on together. But I really think that very often those perceptions come from misunderstandings about how decisions are made, who has authority to make certain decisions and why. And so we can very easily say, oh, well, this person's not being helpful or they're being being obstructionist, but like they're working within a set of rules that is not of their making. So I think that there are way more opportunities to work constructively and collaboratively with government partners than we allow ourselves, perhaps because of some of those assumptions. I think it's really important for people to learn more about how government, governments spend money, how they make decisions and how they deliver goods and services. I often like to use the university as an example when I talk to people about how should you be thinking about working with the government? So let's say you wanted to do a project with a university, okay. And you said, well, I'm going to go and I'm going to talk to people and I want to talk to a broader selection of people at the university to find out about this project and I'm going to do that in July. Well, anyone who's been to a university, certainly in the U.S. would say, well, but you can't. Nobody's there in July. Similarly, in governments there are fiscal years and talking to somebody right at the end of a fiscal year is not the right time. Right. To be thinking about how they're spending money. Or, right. The plans for the next year have already been made. Made. The money from the previous year has already been spent. Right. So having, like being cognizant of the cadence of the way that a government works is really important. Another analogy that I think works well with universities is when, if, let's say you wanted to say, well, what does the university think about this? Okay. And people ask me that all the time, well, how. What does the Kenyan government think about this? Okay, well, who do you mean? Okay, like shall we ask the President, shall we convene the cabinet? Governments are these incredibly complex institutions within which there's like a lot of disagreement. Right. And at the same time, there is policy that flows from the top, right? There are structures, there are annual operating plans, et cetera, that you need to understand how to work with. And so I think that understanding the periodicity and cadence of the way that governments work is really important. Budgets, election cycles, the time horizon for policy change. And you know, meanwhile in the development sector, you know, we've got everything works to the time frame of the donor project set cycle, right? You need to put in your reports to the donor, right? They're marching to their cadence, right? Okay. And so working with the government, I mean, it's a big ship, right? It does not turn on a dime and you wouldn't want it to. Right? And so really recognizing that and embracing it as a path to, to massive scale that you have to work within and alongside is absolutely essential in terms of getting things done. I also think one of the most important functions of a government is a coordinating function. And it's all too rare to find development partners that are willing to be coordinated. I remember sitting in a meeting of a bunch of partners in, in the school health space and it was representatives from a bunch of different NGOs, all of whom had grants to coordinate the school health sector. Nobody was there to be coordinated. Right. And so that's what we should be letting governments do and let them coordinate us. And that's hard, right? That's hard.
- [197:38]
Interviewer (Rob Wiblin or host)
Charity founder Leah Uchesheva on how a simple intervention reduced suicide in Sri Lanka by 70%.
- [197:47]
Leah Uchesheva
So we're planning to do this work following the very successful input in Sri Lanka. Very successful intervention in Sri Lanka. So this is where my colleague, Professor Michael Edelston has worked for many years. First he worked as a physician treating patients who self poison, trying to save their lives. However, what he found is that this is not a very effective means of saving lives because in quite many respects, quite many cases it could Be too late and people die after a day or two after reaching hospital. However, what he found is that if you reduce the access to this means, people do not go on to commit suicide. So in Sri Lanka, the situation was such that the suicide rate has increased dramatically after the introduction of highly hazardous pesticides into the agriculture as the result of the green revolution in 1960s. The suicide rate has increased from 5 per 100,000 people to 24 per 100,000 people in 1976 and then peaked at 57 incidences per 100,000 people in 1995. So this is a staggering increase in suicide rates and you can see a direct correlation with the increase in pesticide use. So when my colleague, Professor Michael Edelston and the pesticide registrar at that time, Gaminima Vera, have noticed this trend, they thought what kind of intervention could help? So from 1984 to, to 2011, there was a lot of pesticides that were banned in Sri Lanka. The suicide rate in Sri Lanka has dropped significantly. So from 57 instances per 100,000 population in 95, it has dropped now to 17. And this is a 70% reduction in suicide rate. So this is a very, very significant success. And this is the greatest decrease in suicide rate ever seen. So those two people, of course there was a team working on this, but these people saved close to 93,000 lives in several years.
- [199:55]
Rob Wiblin
Wow. There was a 70% reduction in suicide across Sri Lanka as a whole?
- [199:59]
Leah Uchesheva
Yes, yeah. Not only pesticide suicides, but 70% reduction in suicide rate at all.
- [200:06]
Rob Wiblin
Yeah, that's extraordinary. And it lines up just with exactly what the dates where these pesticides were withdrawn.
- [200:12]
Leah Uchesheva
Exactly, yeah, exactly. And this incredibly successful interventions are mirrored in Bangladesh and South Korea, where the highly hazardous pesticides were banned and suicide rate has decreased significantly.
- [200:25]
Rob Wiblin
Has anyone written a paper where they've tried to estimate exactly how many lives you'd expect to save and how much it costs? I mean, if indeed it really costs anything other than the advocacy required by some activists.
- [200:36]
Leah Uchesheva
Well, of course, introducing this public policy feature will cost quite a lot of money, because first you need to go ahead and estimate which pesticides are used for suicides in this particular country. So here, I must say, there could not be just one list of pesticides that you just decide to ban. And this will work for every country. Each country uses their own brand names, maybe it's generic name, maybe it's different compounds, different mixtures and solutions that different active ingredients of pesticides are produced. So each country needs to do its own research in terms what substances are used for suicide. And then of course, there will be some cost of implementing those bans. I must say that it's important to also monitor what substances are sold in in shops because quite often there is illegal trafficking of pesticides and some substances that are not legally registered within the country may find their way to farmers markets and shops in the country. So all this needs to be counted as the cost of the intervention. However, we estimate that the successful intervention could cost as much as 400 per life saved. And this is what happened in Sri Lanka. And it could be an extremely, extremely effective intervention in terms of cost effectiveness.
- [202:04]
Rob Wiblin
Is it expensive for you because perhaps you have to lobby against the manufacturers of these pesticides?
- [202:10]
Leah Uchesheva
Right now we're starting work in two countries in India and Nepal. And we exactly selected those countries because we think that we could could implement a highly cost effective intervention in those countries. We have a good network due to my colleagues, Professor Michael Edelston, long work in the region. We have a good network of pesticide registrars that understand the situation and that are on board with our goals. And we also have a good network of United nations experts who, as I mentioned previously, have designed the cost effective and the best policy interventions to prevent suicide and ban highly hazardous pesticides. So due to that, we think that we could be effective in doing this in those two countries. But what we're planning to do is to first collect information from 20 hospitals in India and 10 hospitals in Nepal. And based on that information, we present policy choices, clear policy choices to decision makers in these countries. And of course, we'll work with civil society and we'll work with other stakeholders to engage them as well.
- [203:21]
Rob Wiblin
How do you estimate the probability of successfully getting law reform in a particular country?
- [203:28]
Leah Uchesheva
It depends, of course, it depends on the country. It depends on how ready the civil society is to support our ideas. It depends on how ready the decision makers are to how accepting they are to their ideas.
- [203:42]
Rob Wiblin
Have you generally found politicians to be very sympathetic to the cause and open to banning these pesticides?
- [203:49]
Leah Uchesheva
Usually I would say yes, because the countries we're planning to work with and we work with now have low capacity and they have low budgets for this particular intervention? Usually this one or two people working in the pesticide register office and they're overworked, they don't have, they have little support, they have little knowledge how to use those highly sophisticated tools that the UN develops for them. And they are very eagerly engaged in conversation and in planning on how they could do their work more effective and how they can bring more good to the country. Of course, a lot more attention is currently being paid to environmental harms, to occupational exposure, to incidental exposure of children residues, pesticide residues in food. This is why I think this issue is so neglected. Because when so much talk is devoted to pesticide harms, people don't talk and don't know about suicide by self poisoning with pesticides. And people don't know that this issue could be quite easily resolved with just taking some highly hazardous pesticides away from the market. This is why I think this is to some extent is a social justice and equality issue. Because people who are mostly affected by it, poor farmers in low income communities who quite often don't have a voice and cannot express their own sorrows and their problems. So in many respects it is a call for help which has so far been unanswered.
- [205:26]
Rob Wiblin
So your co founder was initially just trying to help people directly as a doctor in Sri Lanka?
- [205:31]
Leah Uchesheva
Yes, exactly.
- [205:32]
Rob Wiblin
And it sounds like they've had vastly more impact by working on advocacy and policy reform. Like 10,000 times more impact.
- [205:40]
Leah Uchesheva
Definitely, yeah.
- [205:41]
Rob Wiblin
Interesting. So this is potentially a good example of how you can have a lot more impact by trying to have more systemic change rather than just going person to person.
- [205:50]
Leah Uchesheva
Definitely, definitely. Law reform and policy reform are extremely efficient ways of preventing lots of inequality and human rights violations in the world. I worked with decision makers and policy people all over the world on many issues and what I found is that there are a lot of bad policies, a lot of bad policies, such as for example, preventing women with children staying in the shelters or preventing people who use drugs from buying clean syringes. These are bad policies, but there's so much they developed more with not because of ill will, they developed because people don't know better. Decision makers don't know better. They are negligent about what problems people real people face. Usually they come from the same gender, from the same social group, mostly male, mostly well educated, mostly in their middle ages. And they don't care about vulnerable groups, they don't care about marginalized groups. However, if they're told about the effects this particular policy, let's say, is having on vulnerable and marginalized groups, they could listen and it will be even more effective if they are told that it will improve the cost effectiveness of their work, if they are shown that their public image will be better viewed by the constituency or by their boss, and so on. So in the policy work it is important to understand that influencing the the decision makers go a long way if you show them the way to do it. Which could be beneficial for them as well.
- [207:35]
Rob Wiblin
How important was it to have strong evidence from an experiment in order to convince policymakers to change the law and other people to get on board with this whole project?
- [207:44]
Leah Uchesheva
That was extremely important. And I think this is why our approach to solving this problem is also unique, because we work with hospitals, with academic groups, academics, on providing highly precise information, on providing results of randomized controlled trials that point in this direction. So I think it is extremely important to monitor and to provide the best academic standards studies behind this.
- [208:21]
Rob Wiblin
Do you think that it was important to have an academic as the founder and leader? Does that give you a lot more credibility?
- [208:27]
Leah Uchesheva
I think so. I think so. We have the entire Professor Edelston's entire academic knowledge as a background to our work. He has worked on this for many years. He has researched the best ways, and he knows everything about this issue. So it gives us leverage to present our views. It gives him the ability to speak the same language with pesticide registers, with WHO and with the fao, with UN agencies. So I think it's extremely important to have an academic as a head, definitely, especially in our case.
- [209:03]
Interviewer (Rob Wiblin or host)
Karen Levy on working with academics to get the best results on the ground.
- [209:10]
Karen Levy
In academia, you're trying to find the optimal answer or the optimal solution, but in a policy setting, you're trying to optimize within constraints. You don't have an unlimited set of options from which to choose, right? And so the way you would construct a study or the way you would ask a certain set of questions is really very different. The timeframes are really different, what success looks like and how one is rewarded for a study happening well or not. They're just very, very different. But I think that even though these differences exist, many of the examples that we have of programs that have scaled successfully have been ones that have been driven by academics who really care about the policy influence of their work. And I think the reason that matters is because evidence isn't just a set of answers that you pull off the shelf. In taking something from a study to scale, all kinds of questions come up about what are the underlying mechanisms? Why did we do it that way? Well, if we change that, are we now pulling apart the whole theory of change, or is that still going to work? And so I think some of the most exciting examples of of times when studies have moved from evidence to scale have been when you have a really committed academic who's willing to kind of take that journey with policymakers. There is some tension between sometimes what a program needs from a Data and evidence perspective and what is attractive to an academic. Sometimes you really just want to replicate something or you need a bunch of discrete statistics. And this is not necessarily what's going to attract the attention of a world class development economist. At the same time, many of those world class development economists, we're lucky to have them involved and caring about the impact of their research. And so I find it's really useful and important to have an open conversation with academic partners about what would make it interesting for them. And I have found that almost always people are absolutely willing to do the less sexy stuff if you also allow them to ask some really interesting, innovative questions that will drive their research agenda. And nine times out of 10, that part of it is going to end up leading to new insights that affect your work anyway. And so the marginal cost of, of adding another module to a survey or trying a slightly different version of an intervention, doing that can create the space for intellectual engagement from top thinkers and then brings those people to the table for all of the other things that you need. And so I think we should have those conversations.
- [212:15]
Interviewer (Rob Wiblin or host)
Jamie to Bendarana on the value of working with local researchers.
- [212:21]
James Tebendana
It's very important to have local research institutions and researchers with the capacity to identify research needs and to participate and really lead on research. Either it's operational research or implementation research, clinical trials, a variety of research is really important, important and we've seen it for seasonal malaria chemo prevention. One of the reasons why the research on the efficacy of seasonal malaria chemo prevention was very quickly adopted in the Sahel was because a lot of those studies were done by national researchers.
- [213:00]
Rob Wiblin
I see, okay.
- [213:01]
James Tebendana
And so as the results were available, they were able to link up with their counterparts in the ministries of health to speed up the process of the adoption. So the adoption process was quite rapid and straightforward. One of the things we did in Uganda was we had regular meetings between researchers and ministry officials. And in one of these meetings, there's this molecular scientist that was describing the genomics of mosquitoes and insecticide resistance. And then you had the decision maker in government who was sitting there listening and after his presentation saying, in this parts of Uganda, the mosquitoes are resistant to this, they have this molecular genetics. And he looked at the scientist and he said, so what are you saying? Are you saying that I need to buy an insecticide for that mosquito here, another insecticide for that mosquito there and there, and yet I have money to buy one insecticide, so can you make me understand how I'm going to be able to achieve my objectives with one insecticide. And you had this conversation between the science and the implementation and it was a really lively conversation. And so you want to be able to have those conversations at country level. You want to be able to have those conversations ideally in a manner that emphasizes trust, in a manner that emphasizes evidence and neutrality. I mean, my personal experience, again working in research in different settings is that having institutions with the capacity to do research in their context is a critical success factor for the adoption of some of these interventions and maintaining their quality. Because once you've introduced, you still need the operational research, the monitoring and evaluation to identify what's going wrong, what's going well. Well, and then tweak those in the setting to make sure that you continue to maximize and optimize the impact.
- [215:05]
Interviewer (Rob Wiblin or host)
Lucia Coulter on getting buy in from both industry and government
- [215:11]
Rob Wiblin
Is corruption ever a factor here? Has there ever. Maybe testing has been going on, but someone's been getting paid off to ignore the issue or not report that there's letters in paint.
- [215:23]
Lucia Coulter
Not that we've come across. Yeah, not that we've come across. The main thing that's going on is just this kind of lack of resources and then sometimes the lack of awareness as well. The other thing is that there isn't really like a big lead paint lobby.
- [215:36]
Rob Wiblin
That's good to know.
- [215:37]
Imran Rasul
Yeah.
- [215:37]
Rob Wiblin
I don't know why I'm laughing, because I don't know. But there are so many industries where there is a lobby in favor of the bad thing.
- [215:42]
Lucia Coulter
Yeah. There isn't a huge amount of industry resistance and in fact industry is sometimes supportive of regulation because they might want to switch to lead free but they don't want to be undercut by people that aren't. So there's this relationship between regulation and industry where industry might be pro regulation if it's going to be enforced across the board because then it creates this level playing field. And then also the government authority is more keen on regulation if industry is on board because they don't want to do something that's going to be really difficult to enforce or something that's just not going to be feasible. And so, so there's kind of this bidirectional thing where if it just happens, everyone's happy with it.
- [216:24]
Rob Wiblin
I guess that's quite different than climate change worries about fossil fuels because the whole goal is to use less fossil fuels. I guess if you were an energy company that was completely indifferent between supplying oil versus wind energy, then that might be an analogous situation. But that's of course not how it is and likewise with smoking, the idea is not you gotta switch to a different cigarette, it's that you gotta stop smoking and so their product doesn't get consumed. But so long as people are going to continue consuming the same thing in roughly the same quantity, then regulation is much more straightforward to get up.
- [216:51]
Lucia Coulter
Yeah, exactly.
- [216:52]
Rob Wiblin
Have you found any messages in your emails or your meetings that are particularly motivating to policymakers or even to paint suppliers in these countries?
- [217:02]
Lucia Coulter
Yeah. So with policymakers, I think the local data is really, really important. So the paint study data or the fact that. That we are offering to do a paint study with them, I think that's really appealing. That, okay, they can generate this data that's really important for understanding the situation, relevant to their kind of role in government. Other messaging that's I think quite important is about the feasibility, as I mentioned. Practically, they do really care about this being feasible for industry because, yeah, I guess it's like if it's just going to be near impossible to enforce, then what's the point? And also, I don't think they want to be causing huge economic harm or something like that. So the feasibility is important messaging. I think another one is the international precedent. So the fact that lead paint regulation is. Other countries are doing it. It's the future, basically.
- [217:55]
Rob Wiblin
People don't want to be behind the curve.
- [217:56]
Lucia Coulter
Yeah. And I don't think. Also people don't necessarily want to do something that's really unusual. Yeah. So I think that's quite helpful. And then the fact that the WHO and the UN Environment Programme are behind this and there's a global alliance to eliminate lead paint, and there's the UN model law, which is like a model law for lead paint regulation. I think all of that brings a lot of credibility to the issue. But overall it's less about. The majority of our work is less about the persuasion or the advocacy. It's a lot more about the kind of technical assistance. It's like they're on board. How can we help them? So it's about the technical assistance, the providing funding where it's needed and that sort of of thing.
- [218:34]
Rob Wiblin
Yeah, I guess you just have a very. The general observation is that you're having a very easy time. And I guess there's probably a whole bunch of different reasons. One is everyone kind of knows that leaded paint is bad. It's been banned in lots of countries. It's cheap to do. There's no one arguing against it, really. All of the authorities internationally agree that this would be a good thing to get Rid of the health data is fairly clear. It's easy to measure, at least for you to measure the leading paint. So I guess there was just a crazy amount of low hanging fruit here to begin with. You've just found an extremely easy hill to slide down and now you just have to implement it. Is that kind of the basic situation?
- [219:11]
Lucia Coulter
Yeah, that's pretty much it.
- [219:12]
Rob Wiblin
So all of the hard work is done by finding the initial opportunity and then wow. I suppose there's hard work with follow through, but that's kind of the key insight maybe is the original thing.
- [219:22]
Lucia Coulter
Yeah, I think so.
- [219:26]
Interviewer (Rob Wiblin or host)
Alexander Berger on reasons near termist work makes sense even by long termist standards.
- [219:34]
Lucia Coulter
Okay.
- [219:34]
Open Philanthropy representative (possibly Alexander Berger)
I think arguments for global health and well being are first and foremost about the actual opportunities for what you can do. So, you know, I think you can just actually go out and save a ton of lives. You can change destructive, harmful public policies so that people can just flourish more. You can do so in a way that allows you to get feedback along the way so you can improve and don't just have one shot to get it right.
- [219:54]
Claire Walsh
Right.
- [219:54]
Open Philanthropy representative (possibly Alexander Berger)
And at the end you can plausibly look back and say, look, the world went differently than it would have counterfactually if I didn't do this, I think that is pretty awesome and pretty compelling. But honestly, if somebody were coming to me and saying I buy the long termist gospel, I'm all on board, I would super be uninterested in trying to talk that person out of it. I think that is great. I think there's not enough long termists in the world. I think the idea that, I mean, I could go on a rant about this, but I really think think that the idea that long termism is new and small is totally crazy and it should be huge and it should be a really popular idea and the world is in sort of a crazy place that people don't understand and appreciate our position in the world, in the universe and sort of how big the future could be. And so I get a lot of value from seeing sort of more concrete impacts on my work and trying to feel like I can work on problems where I can make progress. But I am not at all interested in talking people out of spending their career on longtermism.
- [220:48]
Rob Wiblin
If there was someone who came to you who was kind of on the fence between doing something that was more unusually longtermist and something that was say, within your own umbrella of the work at Openfell and they said, what's the strongest case that you can offer for Doing the latter rather than the former. What kind of arguments would you make?
- [221:03]
Open Philanthropy representative (possibly Alexander Berger)
A really central one in my mind is I think we just don't have good answers on long termism and maybe that's an argument that we should have. The long term team at openfill is significantly underspending its budget because they don't know where to put the money. And when I think about what are the recommended interventions or like, you know, practices for long term risks, I feel like they either become sort of quickly pretty anodyne or it's like quite hard to make the case that they are robustly good. And so I think if somebody is really happy to take those kinds of risks, really loves the philosophy, really excited about sort of being on the cutting edge, long term could be a great career path for them, them. But if you're more like I want to do something good with my career and I'm not excited about something that might look like overthinking it, I think it's pretty likely that longtermism is not going to be the right fit or path for you.
- [221:51]
Rob Wiblin
What are some examples of valuable feedback loops that you've observed that have helped people to have more impact than they might have if they weren't able to see what was going on?
- [222:00]
Open Philanthropy representative (possibly Alexander Berger)
I think a really central one is just being able to see what works and then do more of it, which is kind of a funny low hanging fruit. But I think often in other categories where like you don't even know sort of what intermediate metrics you're aiming for, you don't have that benefit. So for instance, you know, the amount of resources flowing into cage free campaigns in farm animal welfare has I think well over 10x because they were working and it was like, oh, okay, we have found a strategy or tactic that works and we can scale. And I think that accounts for, you know, a very material portion of the whole environmental welfare movement's impact over the past decade made. But if you were somehow unable to observe your first victories, you wouldn't have done it. And so I think that there's something about literally the feedback loop of knowing if something is making progress is a really, really important one. And also on the other side being able to notice if the bets aren't paying off. So we have a program that's focused on US criminal justice reform and we don't do calculations for every individual grant necessarily. We make big bets on sort of Chloe who leads that program. But if after five years the US prison population was growing, we don't observe the counterfactual but that would raise questions for us of given our cost of this bar and the level of reduced incarceration we would need to be hitting to make this pencil compared to other opportunities for us being able to observe the state of the world and say is the state of the world consistent with what it would need to be in order for these investments to be paying off is an important benefit that you can get in the near termist global health and well being side that you can't necessarily get in the long termist work. I don't think another one is just really boring stuff, but you can run randomized controlled trials that tell you okay, the new generation of insecticide treated bed nets is 20% more effective because the level of resistance before to the old insecticide was reducing it by 20%. And you wouldn't have necessarily known that if you couldn't do the data and improve. And so. So none of those are necessarily order of magnitude kinds of things. But I do think if you think about the compounding benefits of all of those and the ways in which basically the long termist project of trying something and maybe having very little feedback for a very long time is quite unusual relative to normal human affairs, it wouldn't shock me if the expected value impact of having no feedback loops is a lot bigger than you might naively think. That's not to say that long termists have no feedback loops that they'll see Are we making any intellectual property progress? Are we able to hire people? There are things along the way, so I don't think it's a total empty space. But then I think that there's these practical benefits of the global health and well being work that I actually think can just add a lot of value by the long termist flights because of those practical benefits. So a lot of these arguments are in our original post on worldview diversification from several years ago and one of them is just optionality if we think we are going to go through a lot of different causes over time as our thinking changes and I think that's pretty plausible possible global health and wellbeing gives us a lot of knowledge and opportunity to build up experience and causes that might turn out to be relevant. So we know a lot more about policy advocacy in the US than we did five years ago when we were getting started. And that doesn't primarily come from the work on long termism, even though it might turn out to really significantly benefit the work on long termism. A second practical benefit that I think makes a big difference is around feedback loops. So we talked earlier about some areas of just being able to see concretely what is working. I think we can learn lessons about just like what kind of grants go well versus don't. I think there are sort of generalizable lessons there. And a third example is like these very concrete relationships and grantees that have been able to move from one side to the other. So there's an organization that we fund called Waitlist Zero that primarily worked on advocacy around allowing compensation for living kidney donors. And during the pandemic, the person who had started that was able to pivot with some of our funding to start this organization one day sooner that was working on allowing human challenge trials for Covid that vaccines. And if we hadn't been funding the work on Weightless Zero, I don't think he would have been in that position to start the work on human challenge trials. And so I think that's one example. Another example is like some of a grantee from our macroeconomic stabilization portfolio has ended up turning out to be really helpful for a bunch of policy work and biosecurity and pandemic preparedness. And it's something I think we wouldn't have necessarily expected a lot of in front at the beginning. And there's just even more pedestrian stuff like recruiting and fundraising. Eventually we think Open Phil will be a lot more conventionally successful and attractive. If it's like a 50, 50 long termist and global health and well being organization versus if it's like the only thing we work on is AI risk, we think we'd be leaving a lot of value on the table there.
- [226:14]
Rob Wiblin
Yeah, I mean, I think all of that makes sense. I feel a bit uncomfortable with the idea of advocating for doing this big program and spending all of this money just because it incidentally benefits this other program. There's something about that that feels uncomfortable. And I guess you want to put kind of the affirmative case for it first rather than just say as a side effect it benefits the long term. Must work.
- [226:32]
Open Philanthropy representative (possibly Alexander Berger)
I think that's right. And I do think that the affirmative case is first. Like the affirmative case is like you get to do a lot of good. Right. I think that's why people do it. I think it's why people are interested in it. And it's like all this other stuff is like sort of like the third thought. But I don't actually think it's that crazy as a consideration because basically the long termist view should just be a lot more comfortable with this because the long termist view is kind of like everything is these weird bank shots to influence the distant future, right? So anything that you might do to help somebody today, according to long termism, is fundamentally towards the terminal goal of their distant impact on the far future. And so if what you think is that most of the moral value is in the far future and we should act accordingly, you're sort of committed to all of these weird bank shots because there's nothing else in some sense. So I think if people were cynical about it and they're like, oh, I'm going to pull the wool over people's eyes, I think that would be really unfortunate. But I think being honest, that we worry that we might have gotten a little bit crazy seeming here and we like to do concrete good things because that helps people understand that we are motivated by concrete good action. I think there's something about actually making your appearance in line with your true deep values there, where you're like, that's not deceptive, that's just honest and correct. And I find that totally compelling.
- [227:42]
Interviewer (Rob Wiblin or host)
Economist Shruti Rajakapalan on the key skills that to succeed in public policy careers and seeing economics in everything.
- [227:52]
Rob Wiblin
If a student in India who I don't know is like an undergrad or at the end of high school, wants to eventually work on policy reform or like maybe have a career similar to yours, how would you tell them to get started?
- [228:06]
Shruti Rajakapalan
I would say read broadly. You know, economics as a discipline, especially as you go higher and higher into the academy, it becomes very technical. You read only within the discipline. I think if you want to do public policy, if you want to do broader political economy kind of problems, one needs to read broadly. So that's the number one requirement. Be curious about the problems around you and read very broadly. The second thing I would say is pay a lot of attention to local context. And I have had more appreciation for this as I have grown older and as I have written more, because initially the tendency is, is to follow best practices. For instance, you look at what are the best practices abroad and you want to copy them, or you want to look at the best academics. I mean, you want to read everything Milton Friedman has written and be genuinely inspired by it. And I was too. But I would not make the error, I hope, of applying what Friedman says one on one to what is happening in India without considering local context. I think local context is just incredible important. And academia tends to reward people who walk away from it. And I think, you know, within the culture of public policy, we need to reward people who are more Rooted in local context. And I think the third is epistemic humility. And this is not just for people who are starting out in public policy. Actually, they might have a lot of it. I think this is more for the rest of us who've been doing this for a while and some people who've been doing it for a very long time. You know, the idea that there is a single best answer out there, right, and we can both get the data to confirm it or to deny it and, you know, prove it. I don't think we have anything like that for public policy. You know, we don't have any of these eureka moments you might have in natural sciences or hard sciences in social sciences. So I think we need to really carefully think about what it means when, you know, we read a study, what does an empirical paper mean, Whether it confirms our bias or it tells us something different about the world. So I think epistemic humility combined with local knowledge and context, combined with just really broad reading, everything from literature to law to history to culture, mythology, I think that really helps. That's how I was raised to think broadly about the world, to travel, to pay attention to the arts, to pay attention to literature. And that's sort of how I have formed my view of the world.
- [230:39]
Claire Walsh
World.
- [230:39]
Shruti Rajakapalan
I see economics in everything. I think it's an incredible discipline. I think the way one sees the world, once they have been trained in economics, you can never unsee the world that way. You know, I mean, and the greatest strength of economics is that it makes you pay attention to things that are not visible, right? It makes you think about unintended consequences, or, you know, to borrow Frederick Bastiat's great phrase, the scene and the unseen, right? So it makes you think about the unintended consequences, the unseen effects. So economics is just a fantastic discipline. It's got a great, very sensible sort of methodological core in terms of rational choice and the ability to apply it to everything from, you know, constitutions to culture to history, to religion, you know, to crime. You know, in that sense, I'm certainly one of those Chicago School type economic imperialists. I see, I see it in everything. So I think the economic way of thinking is very powerful. So my, any student who asked me, especially if they're working in public policy, which has so much to do with trade offs, right. And costs and benefits, I would say an economics education is both thrilling if it's done the right way and it is invaluable. You know, so economics and everything, you can read broadly, but get Trained in economics. So that is one thing I would say. I think the other moves are, you know, it's very means and ends linked, right? I wanted to be an academic, I wanted to be a professional economist who teaches economics. In that sense, the minimum academic degree you need to do that is a PhD, right? And that's the way to think about it. But there are many ways to do good in the world which have nothing to do with academic affiliation or getting a PhD or going to law school and things like that. So the Effective Altruism Project is a great example of that, that some something you guys do really well. So I think people just need to decide what the end goal is and accordingly pick the means to achieve the goal. So for those who want to work in formal public policy, you know, this might be the government think tanks, you know, all your multilateral organizations and agencies like the World bank and things like that. You definitely need advanced degrees in economics, social sciences, public policy to achieve. If one wants to be a lawyer and think about all the constitutional issues I'm talking about, it's really helpful to have a law degree. It's sort of a little bit hard to talk the talk and think the think outside of the legal training. So I would say for those things it's useful. So it really depends on what the end goal is. But if we're asking about really bright young people who want to be informed, engaged citizens, read broadly, but also read economics, it just takes you a very long way in a way that I think no other discipline does.
- [233:24]
Rob Wiblin
Great. And then if there were listeners from the US or the UK who are really interested working with or in India and wanted to sort of get a start, is there any different advice that you would give to them?
- [233:39]
Shruti Rajakapalan
Understand the local context. Once again, you know, it's very. It's harder when you're a foreigner, and sometimes I'm a foreigner in India because I don't speak all the languages, I just speak two or three of them. So, you know, just really understanding, knowing the language helps. I know a lot of, you know, political scientists and economists who work in India, and they all learned the language of the area where they were doing their field work or running their randomized control trial and things like that. So I think that's very important. I think having a network helps if you're doing academic work. You know, you need to be able to go there, raise grant money, work with local people, you know, co author, publish. So, you know, try and formulate network networks. Go to a department where there are professors who are working on India. You know, for the non academics, I would say there are so many ways to support India, starting with emerging ventures. You know, I might as well plug what we are doing here. But you know, if someone just has an interest in India and understands the value of the, you know, sort of like the moonshot value of doing anything in India and how a little bit of money and few resources can really enable people to change, change the world in a big way. For a large number of people, I would say support philanthropic efforts in India. And it need not be emergent ventures. It could be anything. But Emergent ventures supports very particular kind of ideas. So if anyone likes those, I would definitely recommend ourselves. And you know, overall, the best way to learn about India, many people think is reading, but I think it's traveling. If people just want to learn more about India, just go there, you know, spend some time there, find some friends there and then you go from there. It's the way I learned about the United States. I think the rest reverse will be true in terms of learning about India.
- [235:17]
Rob Wiblin
Makes a lot of sense.
- [235:22]
Interviewer (Rob Wiblin or host)
J Pal lead Claire Walsh on her career advice for young people who want to get involved in global health and development.
- [235:30]
Claire Walsh
Sounds like you have really a very senior role in J Pal, but you're only 29, right?
- [235:35]
Yes, that's true.
- [235:37]
Rob Wiblin
Is it fair to say that your
- [235:38]
Claire Walsh
career has gone pretty quickly, made maybe more quickly than you thought or is this just typical?
- [235:42]
Definitely more quickly than I thought.
- [235:44]
Yeah. How do you think you advanced up the ladder so fast?
- [235:48]
So I'm not sure I have the exact answer to your question, but in my experience, looking at my peers who are involved in similar international development policy work, I think we owe a lot to our master's degree programs. There are a lot of public policy schools that tend to launch people into rapidly rising careers in government and international policy and research organizations. They're called the APSIA schools.
- [236:14]
Okay. Yeah, we'll stick up a. Stick up a link to those. Yeah, it's something we've found in general that across the whole policy sector that people can really end up in positions of serious responsibility late in their 20s
- [236:25]
Rob Wiblin
or early in their 30s.
- [236:26]
Claire Walsh
And people just have to be a little bit opportunistic and hope to be in the right place at the right time. But they can end up, you know, really jumping up a couple, couple of rungs if they're lucky enough to get that situation.
- [236:35]
Yes, I think there's a lot of truth to that.
- [236:37]
So in the past you were working in non profits, maybe can you give us a kind of description of the path you've taken in your career to end up where you are now?
- [236:44]
Sure. So in college I was actually an anthropology major and I had studied abroad in Uganda and knew that I wanted to continue to work in East Africa. And so I started working part time for two small NGOs that had now since grown a lot bigger. Educate and Africa Working on employment opportunities for youth who face a labor market that's just dismal in Uganda and Tanzania, where they graduate high school with all these great credentials and then find that they're faced with a lot of really sorry job options and so trying to find ways that they can start their own businesses or become entrepreneurs. And I was excited to work for them for about a year and quickly realized that I didn't have enough skills to really make it in the international development sector. And so that's why I went back to grad school so quickly. Just after a year of work, what
- [237:33]
kinds of skills were you lacking?
- [237:35]
Karen Levy
So.
- [237:37]
Claire Walsh
Oh gosh, too many to name? So many to name. But I'll never criticize my liberal arts education. I owe everything to it. So I don't knock that either, but I didn't have one. Management skills, accounting, basic business, basic finance, how to fundraise. And then on the more technical side, I was supposed to be working on monitoring and evaluation, but I had no idea about statistics, econometrics, impact evaluation methods. And so I made it a priority to get those skills in grad school.
- [238:13]
And then what did you do after that?
- [238:15]
I immediately upon finishing grad school, I applied to J. Pals Policy wing.
- [238:20]
Okay, wow, right? You got helicoptered in to do some really important work. Where do you think young people should start if they want to. To make, if they want to work on global poverty in a similar way to you? What kind of majors would you recommend that they do?
- [238:33]
Economics, political science, international development.
- [238:35]
Snappy answer. And are there other options or paths in global poverty that you think are promising beyond the traditional ones, like possibly doing entrepreneurship, starting a business in the developing world, or just going and trying to work there in government just directly?
- [238:51]
Definitely. You don't have to go the research route, you don't have to go the Internet national aid route. I think. And I'm very pro entrepreneurship. I think sometimes there's a risk of, you know, I have the one silver bullet solution that's going to solve anything and it doesn't exist and therefore I should create an organization around it. I would caution a little bit against that. There's probably already someone who's working on the problem and it might be more effective if you wanted to go work for their organization.
- [239:18]
Do you think it's important to live in developing countries where you might be helping with policy change? And is this something that people should consider doing in possibly their late teens or early 20s when they have the opportunity to.
- [239:29]
Definitely, and I regret not doing it more. I think if you want to work in international development, having at least two years of experience living in a developing country is a huge plus and can open a lot of doors.
- [239:39]
What is it specifically that you gain from doing that?
- [239:42]
It's so many different things you gain. It's a deeper understanding of human difference, of cultural and ethnic diversity, of being able to live with less creature comforts than you're used to, being able to understand how to get things done in resource poor environments, being able to put your personal comfort behind a greater cause and mission. And then it also gains you a lot of credibility with a lot of major players in working in development to see that you've lived and worked and thrived in lower middle income countries.
- [240:13]
So let's say that you're doing or you have completed a retail relevant undergraduate degree. How can you go about kind of building a professional network in global poverty reduction? And how could you kind of experiment with different options that you might have in that whole field when you're in your mid-20s?
- [240:29]
So it's not the prettiest answer. A lot of people right out of undergraduate first take an internship that's often unpaid and often in a developing country, and then they convert it later into a paid position. That's what I did. That worries me because I think internships should be paid, but it is what a lot of people do. I think what really helped me build my professional network in international development because I wasn't lucky enough to get into an important institution right out of undergrad. I was working for very small niche NGOs, was going back to get my master's and that completely exponentially grew my professional network and gave me connections to all the major organizations that I would hope to work for.
- [241:08]
So it sounds like perhaps the most
- [241:10]
Rob Wiblin
important thing that we can learn from
- [241:11]
Claire Walsh
your career is the value of doing one of these excellent master's programs. Obviously I've said what you studied, but are there any other programs that people could try to get into that could really help to advance their career?
- [241:21]
Yeah, if you're interested in public policy and international development particularly, there is a group of schools called the APSIA Schools. I don't remember what the acronym stands for, but it's a group of about 25 master's programs at universities around the US and I think maybe a couple in Canada that have high quality master's degrees in these fields. They include Princeton's Woodrow Wilson School, Harvard's Kennedy School, Johns Hopkins School for Advanced International Studies, George Washington, Georgetown, American Denver University, a lot of universities in California. And so it's a lot of great public policy schools out there.
- [241:59]
That's a really useful list. How do you think doing a master's compares to doing a PhD? Have you considered doing a PhD yourself?
- [242:05]
Definitely consider doing a PhD myself. So doing a PhD in order to make policy change is not one of the top things that most people going into a PhD are trying to do. And I'm really proud of the ones who are, and I would encourage more and more to think about it. But going into a PhD is really great for becoming an academic or a full time researcher. But I knew I wanted to work in policy action rather than a full time research.
- [242:33]
That makes sense. I guess most of the people, you know, the principal investigators will have PhDs at J Pal, right?
- [242:38]
Rob Wiblin
So if you want to go into
- [242:39]
Claire Walsh
kind of hardcore social science research, then the PhD is kind of necessary.
- [242:43]
That's correct, yeah. If you want to be a principal investigator on an impact evaluation that you hope might someday be published in an academic journal, you need a PhD.
- [242:53]
What are the differences you found between working in academia versus the nonprofit sector? And do you feel like you're a much more better fit for one than the other?
- [243:00]
So in academia there's much more room for skepticism and I think that I am potentially more suited to that in nonprofits. I think it was really exciting to be working directly with people, providing people directly with services, and I miss that a lot. But I enjoy that within academia there's more room for questioning whether what we think is helping people is or isn't.
- [243:27]
So is the challenge there that if internally you're not so optimistic about the value of the intervention that you're delivering, it could be demoralising for staff. Or is it that it would discourage donors from supporting you and helping you to scale up the program?
- [243:40]
I actually think that a lot of NGOs are very introspective and reflective and are always seeking to question their assumptions and improve their model. It's more just me personally that I have a really hard time working on something if I don't know it has an impact.
- [243:58]
A question I regularly ask people I'm interviewing is whether you Think you would do more good if instead of trying to do good through policy reform, instead you've gone out and tried to make a lot of money and then donated your earnings to help tackle poverty, either doing cash transfers, perhaps, or providing medical services, or perhaps funding a think tank or an organization like J. Pal. Is that something that you have ever thought about or have a view on?
- [244:23]
I've definitely thought about it and in some ways I think it's quite likely that I could have more impact just giving all my money away to cash transfers for the poor. And sometimes I wish I was just doing a daydream about that. But I have a broader goal in mind, which is helping improve institutions and having an optimism decision despite corruption, despite the hurdles of bureaucratic processes, that governments in developing countries have the capacity and the capability to run high quality programs that reduce poverty. And that in some small way by, you know, helping them test their latest innovations before scaling them up or scaling up things that RCTs have shown to be effective in the past, that I'm also contributing in some very, very small way way to those institutions being more effective to deliver quality services to their citizens.
- [245:13]
Yeah, it sounds like J. PAL has quite a lot of traction with developing world governments and their budgets often very large. So it would kind of surprise me if you could have more impact by just, by just donating the money. Maybe you have potential to earn more money than what I appreciate. But I expect that the changes in budgets you're getting through J. Pal are probably doing more good than that.
- [245:32]
I would just have to get out my spreadsheet.
- [245:35]
So do you feel like your career track has been risky at all? I mean, initially you're working at nonprofits in the developing world. Did you ever feel like you weren't sure what your. What your next position was going to
- [245:46]
Rob Wiblin
be or whether you'd be able to,
- [245:47]
Claire Walsh
you know, transition into. Into other problems if you decided that you didn't want to work on global poverty anymore.
- [245:52]
So I will say that early on in my career I was very worried that by working for small NGOs that I couldn't transition into work working for big NGOs, foundations or policy organizations or research organizations. And I was quite pleased that that wasn't the case at all. And obviously the master's program helped with that a lot. But it was possible to go from a smaller NGO to a bigger organization like J. Pal. I do think that it is harder for people who go into public policy to then go into the private sector. And that's something a lot of my peers think about and struggle with a lot. There is definitely organizations value skills from the private sector and from the business world. And I feel like it's usually easier for people to switch from the private sector to the policy space or the public sector rather than the other way around.