I’m a doctor working towards the dream that every human will have access to high quality healthcare. I’m a medic and director of OneDay Health, which has launched 35 simple but comprehensive nurse-led health centers in remote rural Ugandan Villages. A huge thanks to the EA Cambridge student community in 2018 for helping me realise that I could do more good by focusing on providing healthcare in remote places.
NickLaing
Karma: 8,309
Jesse I don’t think your example is correct because did the GiveWell error bars don’t overlap with food kitchen ones. We can be 99+ percent sure malaria nets are more cost effective than soup kitchens. That just isn’t the case here. Comparing the certainly of human intervention effectiveness vs. animals is like chalk and cheese
I don’t agree with Henry that the huge error bars make RPs welfare ranges useless, probably because I value certainty a bit less than him. But I do think if we value certainly to any degree that can reasonably make us de-value animal welfare point estimates as RP demonstrate themselves in their moral parliament tool.
Love that this has been curated. Underrated argument making nice bold claims understandable to all us plebs. Nice one.
Thanks for this write up. I had no idea about any of this! I’m as bit disturbed by Makary’s response to your “change your mind” question. Character, integrity, balance, and ability to compromise really matters when it comes to leading institutions, not just being smart and having good ideas.
Making new discoveries is often helped by some contarianism yes, but I’m not sure it’s the best trait for running an institution.
Like you I hope they will do well!
Although it’s an interesting question, I’m not sure that gaming out scenarios is that useful in many cases. I think putting energy into responding to the funding reality changes as they appear may be more important. There are just so many scenarios possible in the next few months.
PEPFAR might be the exception to that, as if it gets permanently cut then there just has to be a prompt and thought through response. Other programs might be able to be responded to in the fly, but if The US do pull out of HUV funding there needs to be a contingency plan in place. Maybe gaming scenarios is useful there, but only if whoever is gaming it actually has the influence either to fund scenarios that do arise, or informed those that fund. Maybe the WHO is doing this but they aren’t very agile and don’t communicate much on the fly so it’s hard to know
I think pepfar and malaria tests and treatment donations are among the most important and large scale funding gaps that need to be considered responded to in the short term. Even if stocks remain for the next few months, if they aren’t delivered because those organizing their delivery didn’t have jobs then that’s a big problem.
I do think that governments need to take some responsibility too. If you have the medications you probably can switch manpower to delivering them, even if you hadn’t budgeted for it because you expected USAID was going to fund that indefinitely. This is the situation for malaria and HIV commodities which are often there in decent quantities but sometimes aren’t being distributed effectively right now.
The vast majority of other USAID programs I don’t believe are super cost effective, so as super sad as it is that they are gone and no longer helping people, I don’t think it’s wise to consider covering their funding in most cases as that money would be better spent on more cost effective charities.
“The poor should be thanking the rich, not resenting them. The rich are the reason why the poor are getting by at all. Many of the poor are not pulling their own weight, while the wealthy are pulling much more than their weight.”
Unfortunately this comment (rightly or wrongly) has made me somewhat doubt the integrity of some of your other arguments and comments. I feel like its important to say that I strongly disagree with this line of thinking and find it a horrble way to look at the world, and people who are far worse of than us.
I see no reason why my super poor friends here in the village in Uganda should be “thanking the rich”. The world has developed around them, and their quality of life has not improved to the extent that it should have, given how many resources there are in this world. Their educational opportunities and healthcare remains unnecessarily terrible.
I was thinking of arguing against your points line by line, but I think that will do more harm than good.
The reason for this global trend is because Global income inequality has decreased globally (mainly because of India and China’s development), whereas within individual countries in general inequality has been increasing over the last 50 years—which is what matters most in people’s perception. At the level of the nation state, which is what matter socially, inequality has drastically increased—especially right at the top end of wealth.
I agree with Pinker that inequality is not quite as bad as a lot of people think, but wanted to get the facts right here.
Thanks Tom! No I wouldn’t generalise that broadly, I’m sure there will be some cases where it might be cost effective to get some bridging funding in there. For me it’s less about the nature of the program, and more about whether there’s are tipping points in the vulnerability of the people being cared for.
If we take top GiveWell charities as an example, in situations like mosquito nets, vitamin A, distribution, deworming if those stopped for a year they could probably be started again fairly easily in a year without disproportionate harm. The lives lost would mostly be just because there were less nets delivered (the same as is they had less funding in the first place), not because of some disastrous vulnerability exposed.
A counterexample which might have merit to fund might be something like a malnutrition program where you are halfway through giving rutf to 100,000 kids. Maybe you have enough RUTF to feed the kids but USAID has cut funding for staff. Lots of benefit from the first half of the program would be lost of you didn’t fund staff for the second half. Maybe this would be worth paying the staff to finish the program—assuming it’s a relatively good malnutrition program without hugely bloated salaries as USAID projects often have. In saying this you could probably offer the staff half their USAID pay to come back and finish the program and nearly all would—even more cost effective (this might sound callous but I have discussed it here before)
Or something like a highly effective gender based violence program that was halfway through—you might have very little benefit for people if the program remained unfinished, so finishing it might really be worth it.
I’m not saying most projects are “resilient” as such—without funding they will stop. Just that most could be restarted again relatively easily in future without huge extra expense.
The problem is you can’t trust NGOs to tell you the truth on this—almost all are hardwired to use disasters in any way they can to raise more money. You’d have to investigate the real situation on the ground pretty hard. I was horrified during covid how many NGOs unrelated to health managed to make spurious arguments why they needed way more money.
By the way if anyone is considering funding stuff on a big scale in East Africa, in happy to get on a call and give you my 10 cents (“my 2 cents is free”)
I don’t have a big issue with much of this philosophically, I’m just extremely skeptical about the validity of most small percentages.
My intuition is that small percentages are often greatly overestimated, therefore giving far higher expected values then is really the case. My inclinations is that where uncertainty is greater, numbers are often exaggerated. Examples where I have this intuition is in animal welfare and existential risk. This seems like it should be testable in some cases. Although it might seem like a strange thing to say, I think conservative small percentages are often not conservative enough.
Often I think that pascall’s mugging is a mugging as much because the “low” probability stated is actually far higher than reality, than just because the probability is low persay.
I don’t have any data to back this up, obviously we overweight many low probabilities psychologically, things like probability of aeroplane crashes and I feel like its the same in calculations. This has almost certainly. been written about before on the forum or in published papers, but I couldn’t find it on a quick look.
Thanks for this initiative! My somewhat thought through take from someone who knows a bunch of people who lost their jobs and who’s work has been mildly but meaningfully affected by USAID cuts is that I would be slow to throw money at projects previously funded by USAID.
Most USAID projects just won’t be the most cost effective place to put your dollar, even if cost effectiveness might be slightly increases by providing a bridge to get them restarted. As much as cutting the aid abruptly is doing large amounts of harm and feels terrible, if the original project is only moderately cost effective it might still not make sense.
Most orgs and projects are often surprisingly resilient to pauses, especially in sub Saharan Africa. There are very few cases where the work wouldn’t be able to restart in a few months if funding was returned from somewhere else. This points to me against the “bridging” argument drastically increasing cost effectiveness above what it would have been for the project anyway.
f you do choose to get involved, talk to a lot of people before deciding. Other funders are thinking the same thing about whether to get involved in similar initiatives, and they might have done a bunch of research on it too. For example I know GiveWell are thinking about this too.
I don’t love that the site doesn’t have actual links to the work that’s being funded. For example one case seemed super dubious to me “East Africa, one entity cannot make a $100,000 purchase of life-saving HIV/AIDS medications and another cannot purchase $50,000 worth of nutrient-dense foods for children, both because of the freeze on U.S. foreign aid.”
To the best of my knowledge. East African countries still have enough HIV meds for a few months at least, and I don’t know much about of parallel programs that would purchase medication separately like this. I’m not saying it’s necessarily wrong but I’d like to hear more.
I really like these frameworks, lots of interesting communication ideas, and I do think some of the old EA communication classics have find a bit stale. I especially like the blue ocean thing. Nice job!
Ha I love this I will definitely check that simulator out nice one!
This is fantastic thank you! Have already sent it to someone considering dong a CBA
“For any purpose other than an example calculation, never use a point estimate. Always do all math in terms of confidence intervals. All inputs should be ranges or probability distributions, and all outputs should be presented as confidence intervals.”
I weakly disagree with this “never” statement, as I think there is value in doing basic cost-benefit analysis without confidence intervals, especially for non mathsy indivuals or small orgs who want to look at potential cost effectiveness of their own or other’s interventions. I wouldn’t want to put some people off by setting this as a “minimum” bar. I also think that simple “lower and upper bound” ranges can sometimes be an easier way to do estimates, without strictly needing to calculate a confidence interval.
In saying that when, big organisations do CBA’s to actually make decisions or move large amounts of money, or for any academic purpose then yes I agree confindence intervals are what’s needed!I would also say that for better or worse (probably for worse) the point estimate is by far the most practically discussed and used application of any CBA so I think its practially important to put more effort into getting your point estimate as accurate as possible, then it is to make sure you’re range is accurate.
Nice job again.
Thanks Jason—those are really good points. In general maybe this wasn’t such a useful thing to bring up at this point in time, and in general its good that she is campaigning for funding to be restored. I do think the large exaggeration though means this a bit more than a nitpick.
I’ve been looking for her saying the actual quote, and have struggled to find it. A lot of news agencies have used the same quote I used above with similar context. Mrs. Byanyima even reposted on her twitter the exact quote above...
”AIDS-related deaths in the next 5 years will increase by 6.3 million”
I also didn’t explain properly but even at the most generous reading of something like After 5 years deaths will increase by 6.3 million if we get zero funding for HIV medication, the number is still wildly exaggurated. Besides the obvious point that many people would self fund the medications if there was zero funding available (I would guess 30%-60%), and that even short periods of self funded treatment (a few months) would greatly increase their lifespan, the 6.3 million is still incorrect at least by a factor of 2.
Untreated HIV in adults in the pre HAART era in Africa had something like an 80% survival rate (maybe even a little higher) 5 years after seroconversion, which would bring a mortality figure of 3.2 million dying in 5 years assuming EVERYONE on PEPFAR drugs remained untreated—about half the 6.3 million figure quoted. Here’s a graph of mortality over time in the Pre HAART era. Its worth keeping in mind that our treatment of AIDS defining infections is far superior to what it was back then, which would keep people alive longer as well.
https://pmc.ncbi.nlm.nih.gov/articles/PMC5784803/
And my 3.2 million figure doesn’t take into account the not-insignificant number of people who would die within 5 years even while on ARVs which further reduces the extra deaths figure.
Also many countries like Uganda have about 1 years supply of medications left, so we should perhaps be considering the 10% mortality after 4 years of no medications rather than 20% at 5 in this calculation, which would halve the death numbers again.
So I still think the statement remains a long way off being accurate, even if we allow some wiggle room for wording like you rightly say we should.
The idea that no (or even few) Sub-Saharan African countres would stand in the gap for their most vulnerable people with HIV, abandoning them to horrendous sickness and death from HIV that would overwhelm their health systems shows lack of insight.
Countries simply can’t afford to leave people with HIV completely high and dry, economically and politcally. HIV medication would be a priority for most African countries—either extra fundng would be allocated or money switched from other funds to HIV treatment. As much as governments aren’t utilitarian, they know the disaster that would ensue if HIV medications were not given and their heallth systems were overwhelmed. AIDS is a horrible condition which lasts a long time and robs individuals and families of their productivity.Granted care might be far worse. Funding for tests like viral load cold be cut, there might be disastrous medicaion stockouts. Hundreds of thousands or even more could die because of these USAID cuts. Funding for malaria, tuberculosis and other treatments might fall by the wayside but I believe for most countries HIV care would be a top priority.
There would be some countries that are either too poor or unstable where this might not happen. Countrie like South Sudan, DRC, Somalia—but I strongly believe that most countries would provide most people with HIV most of their treatment for free.
Besides this, given it is life saving I would estimate maybe half (uncertain) of peopl ewith HIV would buy their own medication if there was no other option—if the alternative is death their family would pool money to keep them alive.
Another minor point is that I think drug companies would likely hugely drop the cost of medication as well—otherwise they wouldn’t be able to sell much of it.
Disclaimer: I think the instant USAID cuts are very harmful, they directly affect our organisation’s wonderful nurses and our patients. I’m not endorsing the cuts, I just think exaggurating numbers when communicating for dramatic effect (or out of ignorance) is unhelpful and doesn’t build trust in institutions like the WHO.
Sometimes the lack of understanding, or care in calulations from leading public health bodies befuddles me.“The head of the United Nations’ programme for tackling HIV/AIDS told the BBC the cuts would have dire impacts across the globe.
“AIDS related deaths in the next five years will increase by 6.3 million” if funding is not restored, UNAIDS executive director Winnie Byanyima said.”
https://www.bbc.com/news/articles/cdd9p8g405noThere just isn’t a planet on which AIDS related deaths would increase that much. In 2023 an estimated 630,000 people were estimated to have died from AIDS related deaths. The WHO estimates about 21 million Africans on HIV treatment. Maybe 5 million of these in South Africa aren’t funded by USAID. Other countries like Kenya and Botswana also contribute to their own HIV treatment.
So out of those 16ish million on USAID funded treatment, over 1⁄3 of those would have to die in the next 3 years for that figure would be correct. The only scenario where this could happen is if all of these people went completely untreated, which means that no local government would come in at any stage. This scenario is impossible
I get that the UN HIV program want to put out scary numbers to put the pressure on the US and try and bring other funding in, but it still important to represent reality. Heads of public health institutions and their staff who do this kind of modelling should learn what a counterfactual is.
I really appreciate you weighing in here Laura. It’s reassuring to have someone from RP speak into this with some recognition of these issues.
So good to see my country of birth positively represented on the forum. Ka pai Aotearoa!
I think this first example isn’t comparable, and a bit of a strawman. The Vox article is about how bad factory farming is, and how we don’t need to do that to help humans to flourish. This discussion is about potentially withdrawing life-saving interventions because they might be detrimental to animals. This directly connects the saving lives to harming animals – the Vox article doesn’t.
I think you’re basically right abobut the ITN counterfactual that if marginal funding goes away from ITNs then it might not go to alternatives. Less donations to AMF might simply result in less ITNS. If this argument though was taken up on a larger scale and AMF reduced net distribution, many people would want to save lives from and kill mosquito malaria regardless. The public health world isn’t likely tolerate malaria rapidly worsening because EAs decided Nets were bad for mosquitos. I think you are mainly right on this point though.
On your imputs, its the 4th that seems most important to me but I’ll comment on the 3rd too.
I don’t think the 3rd input is absurd, but I do think it is probably too animal friendly. Like I said in my critique, their moral range calculation basically ends up as probability of sentience x behaviour score, and because all animals exhibit some of the behaviours they measure I think especially for smaller animals this is likely to overestimate their welfare. RPs behaviour score only really allows for a narrow range of something like between like 20 and 100 so its almost impossible for any small animal to come out of RP’s moral weights caculation with a negligibly small moral weight. In the article I was trying to be very measured and not make huge calls, but if you’re asking me what I might have done differently to weight animal behaviours, then I’d say I would have allowed for a much bigger behaviour score range, perhaps through having more than a binary yes/no system on some of the behaviours – giving less complex pain response behaviors a fraction of more complex ones.
I think the 4th input seems absurd and I won’t rehash this much as many others have made arguments against your reasoning on this thread. You’re translating a figure which is on the upper bound of judging severe human pain (which like Bruce said, by definition can’t last long) directly onto what you think might be happening in mosquitos – a wildly different organism. On what grounds really would mosquitos dying of poisoning likely cause that severe pain at a best guess? I think its possible but very unlikely so I think it would be reasonable for the sake of conservatism to reduce this number by orders of magnitude.
4. On the number of mosquitos front for a start I don’t like comments like “my takeways would probably be the same even if….” Multipliers can add up, and we’re trying to move towards accuracy so I think it can be an unhelpful copout to question how much any element of an analysis matters – Rethink Priorities said things like this a number of times during their moral weights project which was a small red flag for me.
I agree there’s no empirical research on the mosquito number front, but from my perspective having travelled around Africa and living in a grass thatched hut and sleeping under a mosquito net for the last 10 years, 24 mosquitos killed a day on average per net seems extremely unlikely. That would be something like 240 million mosquitos killed by nets alone every day in Uganda – which seems to me perhaps plausible but unlikely. From a distance I think you could have been more conservative with your “best guess”I’ve already discussed the RP thing above thanks!
I think this is an interesting post and warrants discussion, but I ended up strongly downvoting because I don’t want this to be the kind of discussion which is front and center on our public EA forum for external facing reasons and PR risk. This might well be the wrong response and many people might disagree with me on this which is fair enough.
I’ll also flag that find the idea that saving poor kids’ lives might be bad on the account of mosquito suffering makes me emotionally and almost physically squeamish, even if intellectually I think its an important discussion to have.
After flagging my biases, it still seems to me Vasco’s analysis swings unnecessarily mosquito friendly, to the point where it almost feels motivated. I’m not saying it is motivated but there is a lack of “conservatism” or sanity checks in this estimate.
There’s no thought of counterfactuals. Someone mentioned hat mosquitos will die anyway, and that could be painful too which is true. More to the point, without the nets to protect us other mosquito slaughtering options would be used and actually have been used as a kind of net alternative include...
- Indoor residual spraying, which slaughters mosquitos on mass with similar chemicals
- Mass poisoning of water bodies through chemicals (in the past DDT which surely caused animals higher in the food chain to suffer)If AMF and the nets weren’t doing their job, I would guess the alternatives might be at least as bad for mosquito welfare.
As many have mentioned, @Vasco Grilo🔸’s blunt tool of estimating “excruciating pain” seems almost absurd. The idea that a mosquito experiences that degree of suffering as it dies of poison is possible but so unlikely that I think that best guesses for that number should be revised down by orders of magnitude. See other comments for in-depth arguments, I appreciated this comment from @bruce
“I don’t know where exactly to draw the line here, but 14.3 mosquito days of excruciating suffering for one happy human life seems clearly beyond it.”There’s just no way mosquito nets kill anything like 24 mosquitos a day on average. I would guess this at under 5. Basing this estimate on Vasco getting a lot of bites while sitting outdoors at night (Mosquito nets are indoors) doesn’t make much sense.
Anchoring on RP’s moral weights which I argue might be too animal friendly will often mean that any human helping intervention which hurts animals at all might look “bad”. Especially in the case of smaller animals which are extremely different from humans, their use of binary behavioural proxies is almost guaranteed to give high moral weights.
He sent the draft out to review only to animal rights advocates/activists who are heavily invested in this realm of thinking. Involving some more moderate people might be prudent.
That argument is weak to me because you could take any intervention we are clueless about and it would look better than global health interventions within most of the interval. If our interval spans zero to close to infinity then global health interventions are going to be a speck near the bottom of that interval.