On EA messaging—being a doctor in a poorer country
EA has growing communities in low and middle-income countries. Off the top of my head: Philippines, Nigeria, South Africa, Kenya.
This is very good. It also means that EA orgs and communicators should move away from “western-by-default” messaging and thinking[1].
Here’s an instance of how assuming readers are all western can lead to wrong, or at least incompletely thought-through, conclusions.
EA thinking tends to lead people in the US/UK away from being doctors. I’ve heard “don’t be a doctor if you care about people” used as a shorthand for the at-first-counterintuitive recommendations EA can sometimes give.
But, in poorer countries, it might be reasonable on EA grounds to be a doctor:
There is a shortage of doctors in countries like Kenya → higher direct impact
Earning opportunities are much lower → lower impact through counterfactual options [2]
It may be that it still nets out that being a doctor is not the best career choice for people in poorer countries. Seems pretty uncertain, because I don’t think anyone has thought about it in detail. In the 80k hours post, the top-level recommendation “people likely to succeed at medical school admission could have a greater impact outside medicine” is only backed up with evidence from US/UK.
Takeaway: As EA attracts people from all over the world, we need to move away from “western-by-default” communications to ensure people get the correct, and correctly-reasoned, advice.
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In many circumstances it will still make sense to focus on a western audience for different types of communication. But this should be a decision based on the specifics of what you’re communicating, not an unthinking default based on “all EAs are western”
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Quick back of the envelope on this based on stats from an 80k interview with Gregory Lewis:
Assume that over a UK career, a doctor saves saves 6 lives. You could do the same by donating ~$30k (assuming $5k per life saved)
He says it could be 10x in a developing country (here he says it could be more like 40-50x). This would require donating $300k to offset
A very very good job in Kenya would be earning $50k / year. Someone making that much and donating 10% would not donate $300k over their lifetime (unless they worked for 60 years)
-> being a doctor looks pretty reasonable for someone in Kenya, relative to earning to give
High Impact Medicine and Probably good recently produced a report on medical careers that gives more in-depth consideration to clinical careers in low and middle income countries- you can check it out here: https://www.highimpactmedicine.org/our-research/medicalcareers
I am not a medical doctor, but I live in Nigeria. As a lecturer, I have had opportunity to be trained for my PhD benchwork at Duke University, USA. This experience gave me a clue as to the difference between the western world and the low and midsummer income countries like Nigeria. The gap is wide and the differences are huge.
The poor economic situation in Nigeria has necessitated mass exodus of Professionals(Medical Doctors, Nurses, Lecturers) everyone wants to leave to a better economy that pays well.
I support the fact that western by default idea not be seen as good and may not make the desired “good” impacts required in these countries. I also suggest that fund managers with a good knowledge of the African culture should be recruited to help evaluate causes from Africa
Hello Luke,
I suspect you are right to say that no one has carefully thought through the details of medical career choice in low and middle income countries—I regret I certainly haven’t. One challenge is that the particular details of medical careers will not only vary between higher and lower income countries but also within these groups: I would guess (e.g.) Kenya and the Phillipines differ more than US and UK. My excuse would be that I thought I’d write about what I knew, and that this would line up with the backgrounds of the expected audience. Maybe that was right in 2015, but much less so now, and—hopefully—clearly false in the near future.
Although I fear I’m little help in general, I can offer something more re. E2G vs. medical practice in Kenya.
First, some miscellaneous remarks/health warnings on the ‘life saved’ figure(s):
The effect size interval of ‘physician density’ crosses zero (P value ~ 0.4(!)). So with more sceptical priors/practices you might take this as a negative result. E.g. I imagine a typical Givewell analyst would interpret this work as an indication training more doctors is not a promising intervention.
Both wealth and education factors are much more predictive, which is at least indicative (if not decisive) of what stands better prospects of moving the population health needle. This fits with general doctrine in public health around the social determinants of health, and rhymes with the typically unimpressive impacts of generally greater medical care/expenditure in lottery studies, RCTs, etc.
Ecological methods may be the best we (/I) have, but are tricky, ditto the relatively small dataset and bunch on confounds. If I wanted to give my best guess central estimate of the impact of a doctor, I would probably adjust down further due to likely residual confounding, probably by a factor of ~~3. The most obvious example is physician density likely proxies healthcare workers generally, and doctors are unlikely to contribute the majority of the impact of a ‘marginal block of healthcare staff’.
I typically think the best use of this work is something like an approximate upper-bound: “When you control for the obvious, it is hard to see any impact of physicians in the aggregate—but it is unlikely to be much greater than X”.
The ‘scaling’ effect of how much returns of physicians diminish as their density increases is a function of how the variables are linearized. Although this is indirectly data-driven (i.e. because the relationship is very non-linear, you linearise using a function which drives diminishing returns), it is not a ‘discovery’ from the analysis itself.
Although available data (and maybe reality) is much too underpowered to show this, I would guess this scaling overrates the direct impact of medical personnel in lower-income settings: advanced medical training is likely overkill for primary prevention (or sometimes typical treatment) of the main contributors to lower-income countries burden of disease (e.g., for Kenya). If indeed the skill-mix should be tilted away from highly trained staff like physicians in low-income settings versus higher-income ones, then there is less of outsized effect of physician density.
Anyway, bracketing all the caveats and plugging in Kenya’s current physician per capita figure into the old regression model gives a marginal response of ~40 DALYs, so a 15x multiplier versus the same for the UK. If one (very roughly) takes ~20-40 DALYs = 1 ‘life saved’, each year of Kenyan medical practice roughly roughly nets out to 5-10k USD of Givewell donations.
As you note, this is >>10% (at the upper end, >100%) of the average income of someone in Kenya. However, I’d take the upshot as less “maybe medical careers is a good idea for folks in lower-income countries”, but more “maybe E2G in lower-income countries is usually a bad idea” as (almost by definition) the opportunities to generate high incomes to support large donaions to worthy causes will be scarcer.
Notably, the Kenyan diaspora in the US reports a median houshold income of ~$61 000, whilst the average income for a Kenyan physician is something like $35 000, so ‘E2G + emirgration’ likely ends up ahead. Of course ‘Just move to a high income country’ is not some trivial undertaking, and much easier said than done—but then again, the same applies to ‘Just become a doctor’.
Hi Gregory, thank you so much for this thoughtful reply!
This is exactly the kind of discussion and analysis I was hoping to encourage with this post.
Your upshot totally makes sense to me: E2G is probably a bad idea in lower-income countries.
I also buy that being a practicing doctor likely is not the most impactful thing most people in lower-income countries can do either
So what is? A lot of the career considerations probably are still directionally right: government policy, org building at effective nonprofits, research into global priorities, etc.
But getting better answers on these questions is work to be done by EA groups worldwide (much of it on a country-by-country basis as you say—thanks for pushing me on this)
And for what it’s worth, I think the advice you gave in 2015 totally makes sense given the likely audience then. It’s exciting that the audience has changed now and will continue changing.
Hi Gregory,
Very interesting analysis here, but I would add one potential drawback of moving to a high-income country: brain drain. In some countries, there is a lot of lost economic value that happens when highly skilled workers leave developing countries, and it appears that it sometimes (though not always) can harm economic growth. Harming economic growth in a developing country is a bad thing, and can potentially outweigh the benefits of earning to give. The second study I have linked focuses specifically on the negative effects of healthcare worker emigration in Kenya, and though it is a bit old, I think it’s an interesting read.
I was also wondering if you can explain what you mean by “The effect size interval of ‘physician density’ crosses zero (P value ~ 0.4(!)). So with more sceptical priors/practices you might take this as a negative result.” I haven’t encountered some of these terms before so if you could explain them to me I would really appreciate it!
Just off hand-having spent a couple of months in a rural part of Kenya with a severe doctor shortage, the estimate of 1 ‘life saved’ per year of Kenyan medical practice seems off to me, especially in rural areas, but I’m basing this purely off of discussions with people and anecdotal stories so I could be completely wrong. I’ve just heard a lot of stories of patients dying bc there wasn’t enough available healthcare staff in the area. I do think you’re right that investing in less intensive medical training like nursing is probably more cost-effective than investing in doctors.
Sources:
https://wol.iza.org/articles/brain-drain-from-developing-countries/long
https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-6-89
Brian drain is an interesting topic. The brief research and thinking I’ve done on brain drain leaves me without clear answers as to what an individual facing a decision to emigrate should actually do.
Even if it is in aggregate bad that so many people move from poorer to richer countries (which is not obvious to me), it could still be the rational thing to do on an individual basis.
I would love to see a sort of guide based on EA-principles written for people in low-middle income countries considering moving to higher-income countries.
what are the benefits you might provide to the world working in a (potentially higher-leverage) higher-income country?
what about if you stayed in your home country?
for which careers is emigrating likely to make more sense vs. staying, and vice versa?
If earning to give if a key motivator in emigrating, how much would you have to believe you can earn in order to offset any downsides
what about moving to a high-income country for a few years, gaining experience, then moving back and?
Side note: the methods used in the second paper you shared don’t make sense to me. They say that “for every doctor that emigrated, a country lost about: (i) US$ 517,931”, but they arrive at this 517k figure by saying that education costs ~$65k, and then applying compound interest over 32 years. Seems to me it would be more accurate to say that the country lost $65k, plus the medical services that person would have provided.
Couldn’t agree more. Expanding EA to a non-Western context comes with all kinds of considerations and changed messaging. I have found that in a middle-income country like mine people during the fellowship are pretty accepting of the idea that there are some more high-impact careers than being a doctor, but few participants pointed out that that is too general of a statement and depending on what kind of doctor you are you could make a higher or lower impact. For example, in Georgia we had only dozen or less of highly trained epidemiologists to they proved useful during the fight with COVID, even for future infectious pandemics this seems to be an area of medicine worth investing into.
I totally agree. The “western-by-default” messaging that sometimes occurs in EA spaces not only hurts the efficiency of the movement, but also likely turns some people off who otherwise would have joined the community. If EA is truly about viewing all of humanity as equal, then we need to make sure our communication addresses all of humanity equally, not just westerners.
And I’d note that there are lots of EAs outside of the west. I’ve spoken to EAs in the Phillipines, Brazil, Russia… It would be great if we could support them in building EA-linked institutions that are specific to the opportunities and challenges they face.
100%! I’ve been trying to look at how to frame the EA conversation for our Tz chapter, not just for people who grew up here, but also for development workers who are already mostly aligned with the values of EA.
As an additional doctor into a developing country doesn’t equate to the marginal value of how much better that doctor is than you taking the place of someone else there is a much larger benefit as you’ve stated above. Living in rural Tanzania for years, you can see the benefit that (competent) doctors have to the community, and the answer is lots!
As many have commented, I absolutely agree with you.
However, I’d like to comment that all of the inputs for us to shape EA in “non-Western” (or at least non-rich) countries are already there.
For example, in Chapter 2 of 80,000 Hours we can find this line:
Which should tell us that the examples are from “developed countries” because that is the target audience.
However, it is up to us from the Global South to adapt it for ourselves.
Given it is easier to migrate to developed countries as a qualified doctor, medicine may also be a promising earn-to-give strategy for those in developing countries as well, if they wanted to pursue that route.
I live in a middle income country where most people are still relatively poor compared with people in developed world, although not as bad as the global extreme poor. So the uttermost priority for people here are to lift themselves out of poverty. When I occasionally mention that I gave money to charities, everyone thinks that I’m utterly insane. This makes me realize that EA is always going to have a limited audience, i.e., people who live in developed country who have a relatively comfortable life.
I upvoted because I too suffer from the fact that EA Philosophy was created by people of high-income countries, to convert other people from high-income countries.
However, I disagree completely that EA is
In my opinion:
It’s true that a dollar spent on a developed country does less good than a dollar spent on a “less developed” country.
However, a dollar spent on an efficient cause inside your own country does more good than a dollar not spent on EA at all!
So, if the counterfactual for Effective Altruism is… no altruism at all… then it’s better for the world to take a less cosmopolitan worldview and donate mostly to effective causes inside your own country.
Of course, knowing the wild income disparities between even our “middle-income” countries and those from the most underdeveloped regions, I do think that we have a moral imperative to give … perhaps not all that we can, but at least some of what we can.
Full-disclosure:
I donated a little to EA causes, but since sharing my donations with my girlfriend, I decided to save up that money to invest and become an entrepreneur.
My exit plan is for it to become first a source of self-employment and then to sell it. If successful, then I will resume my giving until reaching 10% of profits once I sell the business.