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
Akhil
How much of this decision for the sponsored projects to spin out was at the request of the individual organisations, and to what extent was it initiated by EV?
I think that comparisons about which is a greater scale and which is more neglected is unlikely to be solved in this thread.
I focused on violence against women and girls because the root causes, types of violence and interventions for violence against women and violence against men were sufficiently different that it did not make sense to consider them together.
However, I would certainly be interested in seeing a report on violence against men; I have relatively little knowledge on the field, so don’t feel qualified to make claims about whether it might be a promising cause area.
Thanks for raising this question!
Undernourishment (not getting enough and the right types of caloric intake, a subset of malnutrition) is a massive issue currently, affecting 660 million people; especially in children,[1] it can have significant long-term health sequelae e.g. stunting. And you are right, as a consequence of the war in Ukraine, it is likely to get worse.
Although cash transfers do have a positive impact on degree and rates of undernourishment, it likely isn’t the most directly cost-effective way of addressing this issue.[2]
There are a couple things that we could do (disclaimer: have read about this area before, spent 10 minutes on this):
Fund and scale up CMAM programs around the world- A couple of reviews, including this pretty good one by Save the Children, rate community management of acute malnutrition or CMAM, as one the most cost-effective intervention. CMAM involves treating severe acute malnutrition (SAM), especially in young children, via therapeutic feeding in predominantly outpatient facilities.
Cautiously increase funding in other interventions that are promising- There are several other interventions that may be very cost-effective for undernutrition and malnutrition- Large Scale Food Fortification, Multiple Micronutrient Supplementation for pregnant women, and small-quantity Lipid-based Nutrient Supplementation for children 6-23 months.
Work with governments to create healthier and more resilient food systems- this has a slightly longer ToC but can be quite effective e.g. Reductions in childhood stunting in Peru, from a rate of 29.8% in 2005 to 18.1% in 2011, have been attributed to improved policy and institutional coordination, pooled funding for nutrition and binding nutrition targets, as well as the creation of a civil society platform, the Child Malnutrition Initiative[3]
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More info on the Our World in Data page on undernourishment
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There is mixed evidence here. Some studies have shown it to be reasonably cost-effective (e.g. this one in Pakistan, but this one in Burkina Faso did not)
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Directly from Aid Forum: http://www.aidforum.org/topics/food-security/four-ways-to-reduce-malnutrition/
Yeah great question! There were some similarities and differences from our normal research process
Similarities
We predominantly looked for ideas where there were good feedback loops to measure the impact of the charity and the good that it was doing
Our research process largely worked and could be adapted to biosecurity as a cause area
We considered the potential of the negative impact of our ideas, and ideas where this was more likely were far less likely to pass through our research stages
Differences
We had to very seriously consider information hazards in our idea, which is not a consideration we had given much weight on or considered at all for other cause areas
Had to rely a bit more on expert opinion and ‘lower’ quality forms of evidence like theoretic evidence, case studies
We had a lot more uncertainty about our cost-effectiveness analyses, since estimates vary a lot depending on priors about likelihood of future pandemics and how bad they could be; to an extent, these uncertainties were multiplicative, which made quantification particularly challenging
We had to coordinate and talk a lot more to EA biosecurity folk- the space is small and growing, and it was important to coordinate to make sure we were not duplicating something that was already happening in a way that might be harmful
We are happy to chat to anyone interested in biosecurity who might want to start a charity and wants to talk more about our research process and the ideas we are most excited about in this space
Great post!
I think I would separate out two parts of this post
FMT and being an FMT donor as an effective way to do good
Being an FMT donor as a means of earning money, hopefully to give
On the first, I would be a lot more hesitant about some of the claims that are being made. The evidence for FMT is young, and relatively weak. I think it is far from being a potential treatment of a broad range of chronic diseases; FMT is currently approved for recurrent C. difficile infection in the UK. Things we do not know:
Is it helpful for other chronic diseases? If so, how much and is it cost-effective?
Can it be safely administered at home? You make the claim that donation and use of FMT can happen outside of the hospital setting; this is currently not recommended.
Do we need super donors? There is a growing literature around the effectivneess of autologous FMT (use of your own stool for transplantation) may be as effective as a donation from someone else (one paper I am aware of, but I am sure there are many more). I would be hesitant in putting too much stock in one apprpoach early on in the R&D of this area.
On the second, I don’t have strong opinions. I think it is worth more explicitly flagging that a super donor is quite a rare statistical occurrence, and that the activation energy and cost to be accepted and donate stool for the first time might not make net positive from a cost-effectiveness perspective ( I have not modelled this, but I wouldnt be surprised if this was the case
As someone who occupies a ‘leadership’ position in EA, what is your mentality and approach to fostering a new generating of EA leaders, and making sure that we have a bigger, stronger and more diverse group of ‘leaders’ within the community?
*I don’t necessarily love the use of the words leader and leadership, but think it is a helpful and simple shorthand in this instance.
There is also an active High Impact Medicine community in Aus, with about 15 members and two fellowship cohorts currently running!
Teaching secondary school students about the most pressing issues for humanity’s long-term future
Values and Reflective Processes, Effective Altruism
Secondary education focuses mostly on the past and present, and tends not to address the most pressing issues for humanity’s long-term future. I would like to see textbooks, courses, and/or curriculum reform that promote evidence-based and thoughtful discourse about the major threats facing the long-term future of humanity. Secondary school students are a promising group for such outreach and education because they have their whole careers ahead of them, and numerous studies have shown that they care about the future. This may serve a significant benefit in making more young people care about these issues and support them with either their time or money
Great post Luke! I just wanted to add another argument to point 8:
8. We need to be careful how we talk about ambition (or we might overload and disappoint people)
I think another related aspect to this (in my experience with High Impact Medicine) is that you also want to be careful about this because even though people might be ambitious, their personal and professional situation might preclude them from taking an ‘ambitious’ leap. Even though on the whole I think it is net positive to encourage people to be ambitious, we should also caveat this with an appreciation of different career and life situations. I think a failure to inadequately do this can make people feel like they are not doing or are enough.
Great work. I think point 4 is really interesting:
4. Progress on the policy side is driving progress on the industry side and vice versa
I think this is perhaps applicable to other cause areas where a combination of industry and policy action might be helpful (e.g. corporate campaigns on cage-free chickens and policy change on the same, e.g. incentivising pandemic prevention investment).
How easy/hard was it for you to understand the incentives of different stakeholders and map their relationships?
Do you have any advice for others on how to approach this?
Hey Darren, great point! Fear of violence and the broader affects of that was not something that I had considered, but seems like it is a significant issue that is worth investigation.
In terms of the context within which violence happens (or its source), from my understanding, most of it is within the domestic environment, with the vast majority being by someone who is known to the victim.
Broadly, I think that root cause analysis would be a really interesting step in ‘unlocking’ new and potentially promising investigations in this space. WIth more time, I would love to do this
If you have any more resources on the same, please send them across
Thanks Luke, I definitely think that autonomy and agency, particularly for professionals who are already established in a career, is a good approach to take, and might be a slight difference between community building in university/for professional groups (at least anecdotally, this is our experience).
And on footnote (2), I think this is actually something reasonably important I want to write more about-for instance, in our fellowship, we noticed that people responded well to information that was from well-known sources like high impact journals or news sources, and we found that if we had too many docs from sources they were unfamilar with (EA Forum), it bred some hesitation and skepticism. Although I think there is a wealth of absolutely fantastic material on ‘EA sources’, I think this is an important thing to be aware of in doing outreach to people unfamiliar with EA!
Thanks for this post. Apologies I have not had to read through in detail, but I would suggest that perhaps:
The search criteria that you have used has missed a significant number of papers within the field. Looking at the country distribution you posted, this becomes more obvious; I would suggest looking at the What Works papers that were produced several years ago, where quite extensive literature reviews were being conducted
I think you do acknowledge this weakly, but there is such wide-spanning heterogeneity in the studies that you have included (and the programs the use), that I think tighter sub-group analysis is needed to tease out meaningful conclusions
A lot of work in this space has been done in the last 5-6 years; whilst not a specific limitiation of your work, just something to bear in mind!
Hi Greg,
Thank you for your comment.
Big picture, I wanted to clarify two specific points where you have misunderstood the aims of the organisation (we take full responsibility for these issues however as if you have got this impression it is possible others have too).
1. We do not necessarily encourage people to apply for and study medicine. We are not giving any advice to high school level students about degree choices and paths to impact. To quote what you wrote, “medicine often selects for able, conscientious, and altruistic people, who can do a lot of good if they turn their hand to something else.” We think this is likely true, which is why we think specifically performing outreach to, and helping people who are already studying and practicing medicine find highly impactful careers, is likely to be an appealing option.
2. We foreground transparency in all our communications with our members—and am sorry this is not something you agree with when you write that our reasons are opaque, but I think this is a strong claim to make . We aim to talk honestly about the impact of clinical medicine; discussing the articles that you have written throughout the fellowship as well as other pieces on the issue e.g. Dr Launer’s article referencing yours in the BMJ. We do not have a specific ideology we want to sell anyone on—we want to present people with important information and allow them to form their own conclusions through discussions. Disagreement with EA or existing articles is not something to be feared, but to seek out in order to improve our understanding of impact. We think this is reasonably important for community building
Specifically, I think our difference in opinion is the way we approach the idea of impact in medicine—this involves some specific disagreements (below) but also general framing and outlook.
On some of the specific points:
1. High Impact Medicine not a misnomer- I disagree with your assessment of the situation; yourself, and all the people who you mention in the article, were or are doctors, and fit under what we would define to be High Impact Medics. When you are conducting outreach, I think it makes sense to describe the profession that someone currently has, even if you were to recommend jobs ‘tangential to or wholly apart from’ jobs in that profession.
2. On the career capital and skills of medical degrees for opportunities outside medicine- I think I have addressed the above somewhat in reframing the purpose of our organisation away from pushing students into medical degrees. However, I would push back further on your claim that several years of training and practice as a medic is not good experience for several highly impactful careers. I think that it is quite difficult to attribute how much highly impactful people who are medics can attribute their career success to medicine. For someone like yourself, it might be reasonably easy to say very little.; however, I think there are very likely other individuals for which this is not the case (In our experience, and in having interviews with lots of folk doing highly impactful things, this is the case. In fact, it rings true for several of the medics you mention).
3. For the case of Alice who seeks to maximise her impact as a doctor - I think Alice would disagree with you here and there are a bunch of high impact opportunities within medicine that we foreground:
Health policy work, which is often: 1. taken alongside clinical work 2. in some instances can be done well from a bottoms up approach while working in a clinical setting, 3. Often earmarks and wants the perspective of clinicians.
Effective giving and earning to give- I think doctors in a lot of countries, especially with growth of private medicine, have quite a high earning capacity. Especially for those medics who are further along or who really love their clinical work, earning to give within medicine seems like it might be the best EtG option
Working in a LIC, particularly if you are also involved in training local healthcare workforce, likely has 2-3 orders of magnitude more impact than being a junior doctor in a big metropolitan city (happy to send the studies that support this). I think you and I may disagree on the object level about whether this reaches the bar of “other EA jobs”- I think it might. In addition, if you take into consideration that not everyone has the capacity or capability to do other EA jobs, in a lot of cases, doing some of the above might be the highest impact opportunities for that person.
4. To address your concern about whether our messaging might lead someone to think that clinical practice in a LIC or a giving pledge are equivalently good to the other individuals you cite. Firstly I think this is highly unlikely given the content of our fellowship (with case studies from some of these individuals) and podcast (a number of these individuals are interviewed) and we make clear that there is a range of impact possible from a medical background. Secondly, in circumstances for which that is not feasible or realistic for an individual, or in which that is unlikely to be the case for them, we still think it is robustly good for them to increase their impact 2-3 orders of magnitude in the ways described above.
This is part of ‘big tent’ effective Altruism as we discuss above and may not be something you value as highly as we do. In general though I think this approach is likely to engage a whole lot more people initially than a ‘door in the face’ approach and that encouraging initial steps e.g. pledges or working in a LMIC will increase the likelihood of subsequent change, rather than feeling you have achieved your impact quota. We are reasonably confident that we portray the relative impact of different career options and decisions with high transparency, and enable people to maximise their impact as much they can—though perhaps we emphasise personal fit more than you would.
Speaking to all fellows at a 1:1 level after the fellowship and from the resources they have read over the fellowship, we think the risk we have lost ‘potential impact’ through individuals conflating different career options as equivalently good is very low—and rather the impact of individuals choosing to make impactful career decisions downstream predominates (hence this article).
Happy to chat more about all of this and thanks for your thoughts!
Red team: Why might one not believe in the arguments for wild animals having net negative welfare?
Hey Joel, great report- overall, I am also pretty excited about interventions for hypertension. A couple of questions about your report:
You decided to narrow down on sodium policy taxation advocacy- whilst I think this is probably one of the more appealing interventions in this space, I wonder whether you considered other interventions e.g. community salt substitution, which was looked into by Givewell and recently had a very large RCT conducted.
The impact of sodium reduction extends beyond BP effects- Although the majority of the health effect of sodium reduction does seem to be through reducing BP, there are some other causal mechanisms that are suggested e.g. reducing oxidative stress, reducing sympathetic tone. I wonder whether you looked into/considered these
The cost of advocacy- it seems like you have by and large taken the cost of quite a lean charity doing this. I wonder whether it would be worthwhile looking at organisations that have previously successfully helped advocate for taxation policy, and estimated their size/cost. I would imagine this might be a higher cost by several factors
Are there good advocacy groups out there- I would be really interested to know whether there are highly effective organisations advocacy for sodium taxation policy already out there, that funders might be able to look int further + potentially fund!
A great report- thanks Joel!
Great question :) So this model used accounts for multiple different types of alleviated health burden from each year free from IPV. Specifically, each year free from IPV prevents chronic conditions that cause disability that lasts many years, femicide, as well as acute issues within that year itself. That would explain why 1 year free from IPV can be more than 1, and in this case roughly converts to 2.5 DALYs.
With the caveat that I did not do a geographical assessment in this shallow, I would guess that it would be likely that this would be initially targeted in certain LMIC countries (especially in Africa and Asia) as they have a high and increasing burden of VAWG and have been the focus of prior studies in this space. However, it is also true that the burden of VAWG is considerable and not significantly dissimilar between LMIC and HIC, so I have low confidence on this claim.
Given the uncertainty in the chronology of events and nature of how authorship and review occurred, would it have not made sense to reach out to Cremer and Kemp before posting this? It would make any commentary much less speculative and heated. If the OP has done this and not received a reply, they should make that clear (but my understanding is that this was not done, which imo is a significant oversight)