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: 8,511
Thanks this is super helpful. I was trying to get my head around this announcement and that really helps.
Also to state the maybe obvious, you are allowed to ask whatever you want, and they are allowed to answer it or not! I for one appreciated the question in and of itself regardless of whether it gets answered
Thanks this is excellent. My wife who’s a community organizer always said a small early win should be a almost non -negotiable aim for any advocacy group or organization. Like you said to boost motivation and self belief, increase hope and build confidence in the team and organization. Important stuff.
I think this question would have been b more effectively asked without going through your animal welfare argument for the upteenth time.
If you’re really asking a genuine and important question about the value of direct work vs donating, why not just keep the first paragraph which states your argument well enough, without your second paragraph (which contains most of the words in the question), which is a distraction from your main point which can easily alternate people like me and drag the discussion away from the question itself.
Love this Dylan and completely agree
I know we had a couple of disagreements about the content of your last post, but I really love the transparency and honesty here about your fundraising efforts and the unexpected increased cost of the facility@Anthony Kalulu, a rural farmer in eastern Uganda. It saddens me to say that level of transparancy quite unusula from my experience in Uganda so good on you for that.
Good on you and all the best with your development endeavors.
And like @MathiasKB🔸 said, advise against the crypto investment!
Also I suspect due to the style, and request in this post you might be downvoted quite a bit but dont be discouraged. This forum isn’t an easy place!
Wow amazing 2022 article by the way. I never saw it at the time, it was before I was on the forum!
After reading the thread I might fall marginally more on your side of the argument there, especially as inflation probably did contribute to the trump victory. But it is also yet another demonstration of how hard philanthropy gets, the higher level you get in politics or economics, with so much disagreement and uncertainty. There’s just so much disagreement from experts on almost every major issue, so it’s very hard to know on which side to push the money.
Taking a low percentage “hit based” approach on human welfare issues is one thing, but when it’s super unclear even if you make that hit whether its positive or negative EV is where I start to think why not just take a punt on something deeply uncertain but never negative EV like shrimp instead.
Sorry also to clarify I wasn’t saying you need to provide suggestions, more that there have been a few posts along these lines without any concrete suggestions yet and id love to see some.
Love the post a lot by the way, thoughtful and balanced. Nice one!
I like your point about careers and systemic change, and that it is harder to convert money directly into results. I also agree with @jackva though that measurement problems aren’t a likely reason for the lack of investment, Open Phil are investing in lots of speculative and almost impossible to measure things, I don’t think that’s the issue.
I was encouraged to read this Economist article, “The demise of foreign aid offers an opportunity Donors should focus on what works. Much aid currently does not” which I would say has at least some EA adjacent ideas.
They mention health spending, which by the nature of all 4 of GiveWell’s top charities can often be more cost effective than other options, plus pandemic prevention.
”What should they do? One answer is to stop spending on programmes that do not work, and to focus on the things that might, such as health spending. Even here, however, governments must be vigilant that they are putting their money to its best use. Three principles should guide them.The first is to act in areas where governments (or the UN agencies they fund) have special co-ordinating power, say because they have the security apparatus to reach disaster or conflict zones. Another is to get involved if they have information the public will struggle to assess, about adapting to climate change, say, or a new pandemic. Last, are they funding causes that generate positive spillovers, such as preventing the global spread of infectious diseases?”
Not exactly ITN, but not a bad take either!
I agree with this, yet im yet to hear of concrete ideas which could have significant impact at the kind of high level you are taking about. It would be great to see some ideas fleshed out here on the forum.
I’ve always been a huge advocate for the cost effectiveness of tractable systematic change on the margins, like lead paint policy and my wife’s work to ban certain types of alcohol in Uganda.
But at the really high level you talk about, the “fractured democracy” level I struggle to see where we could have clear impact. It might be one of the least “neglected” areas around, which of course doesn’t mean there can’t be niche highly cost effective areas we could move the needle
Like you suggest there’s also the counterfactual of what if we had been putting hundreds of millions into systemic changes that were then just deleted by the current world order situation. There are good arguments both for and against working on specific programs vs. Systemic change right now. At least the nets still save lives cost effectively as global conflict becomes more likely and global aid is slashed? Given the reduction in aid money donations in global health, donations become a bit more impactful now too.
It’s not as if people haven’t been thinking and even investing along these lines at times. Open Phil have thrust a bunch at “global economic stability”, but this isn’t an area I understand well and feel I can judge well.
https://www.openphilanthropy.org/focus/macroeconomic-stabilization-policy/
There have been a few interesting posts on the forum such as this one recently, but I’m yet to hear convincing ideas—which is not to say those ideas aren’t there.
Claiming the “quantitative model” doesn’t rely on behavioral proxies is technically true but misses the point I think.
The model looks mainly at physiological responses to stimuli. It seems similar to the behavioral model in that if some physiological thing like heart rate or respiration or stress level changes in A similar way to a human then they get a similar score to a human.
I can see the idea with behavioral proxies but I struggle to see what this model really adds. They then seem to bend over backwards somewhat to add other neurological measures that are not neuron count and that will bump up the moral weight as much as possible. “brain mass to body mass ratio” seems especially strange to me in this front
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I agree this is absurd, this is probably the most obvious action open Phil has not taken. What do they have to lose at this stage by filling a lawsuit or at the very least like you say making an official comment.
Perhaps EAs and EA orgs are just by nature largely allergic to open public conflict even if it has decent potential to do good?
Outside of EA, having one major funder is pretty rare. And if you did have no choice but to change or die, I would suggest the best option is often to die, or at the very least go back to the drawing board and consider your assumptions and advantages. The question isn’t “could” your org make the change, but more does it really make sense to do something completely different?
When we get rejected by non-EA funders, its usually things like
- Not much information so we don’t really know (most common)
- You don’t fit the kind of things we fund
- You are too early or too late stage
- We don’t believe what you’re doing is as good as community health workers/systematic change/xxxxx
- You’re not using enough tech
Funders don’t explicitly request large changes because that would be seen as massive overreach.
A funder suggesting an org makes a major pivot doesn’t make much sense to me. Then you’re not even really the same org anymore. I think you’d usually be better to shut the org down and start again if you want to wildly change what you do. If you do change hugely, you’re something new you have no track record or experience there. Outside the EA world funders mostly fund us because reasons like.
a) Think our model makes high impact
b) Trust our org’s team and track record doing what we do
c) Think our finances makes sense
d) Talk to other funders or assessors who recommend us
e) It fits their (often quite narrow) funding criteria
That’s a bit scattergun but hope it helps.
Thanks @Ray_Kennedy that makes a lot of sense. I’ve heard of them in Uganda here more around projects with government and a bit of on-the-ground implementation but the market shaping stuff is interesting and sounds pretty cool. To clarify on the “do many things” front I was more trying to say they are seem like “BINGO” in that they do a wide range of somewhat unrelated programs, rather than they do the same type of things as Oxfam and World vision exactly. They do seem to do a huge range of different things including working with governments, market shaping and direct programs (see @Lorenzo Buonanno’s note). The programs GiveWell is funding on the chart above don’t I think mostly fall under your 2 categories market shaping nor government assistance but I could be wrong—they seem more like direct work.
Thanks @Lorenzo Buonanno makes a lot of sense. I agree that GiveWell sees those programs as cost-effective, my question is more why is it that CHAI is seen as being a trusted organisation to implement these programs when that’s not their primary work and they don’t have years of experience there. I also wonder about the chicken and the egg here. Do these programs exist to access GiveWell funding, or were they doing them anyway and then GiveWell funded them more? That’s not part of my original question though so now I’m the one with mission drift ;).
Thanks fixed!
Completely agree that climate analysis should be a huge part of the scaling AGI equation. I don’t buy the “But AGI might solve climate” argument. It might solve everything, but the uncertainty is so huge I don’t think we should account for that in any equation—I think we should calculate the “knowns:” and largely ignore the wildly unpredictable “unknowns” here.
I don’t think this is the greatest analogy, but I do agree that there are huge risks in imagination. I would say EAs failure (in my mind) through funding Open AI and betting the house on alignment research could almost be considered kind of “play pump-esque” examples. Good ideas coming from the best intentions, but without past evidence as a rock to stand on.
As someone who runs an org that didn’t start work in the “EA world” and only has a minority of funding through EA circles, this is hugely eye opening and even a bit bizzare to me. I can scarcely believe those stories above. I can hardly think of a situation where I would “defer to a funder”. After running an org for 7 years, and working in my field for 11 why on earth would I “defer” to a group who knows far less about what we do than our team?
The funding situation outside of EA is very different among philanthropies. People assess you and your org through what is usually a long and tortuous proces, then see if you fit. Usually we don’t get much feedback. In saying that I’ve had lots of great conversations and suggestions from funders—many of which we have implemented, but I’ve never had one funder ever try and suggest a major change of course, nor make funding contingent on changing anything that’s not really minor.Interestingly outside of EA in the not-for-profit world “Deferring to funders” might be expressed in another way “chasing the money” and is often the sign of a weak and ineffective NGO. Big NGOs like Save the Children, World Vision and perhaps even CHAI shift their focus like the wind to access new pots of money. They then often roll out programs they don’t have expertise in because they just aren’t set up to do that kind of work, spending a lot of money setting up new programs, rather than scaling and refining what they do best.
On a related note I’ve got big concerns around orgs “Pivoting” and expanding their programs outside their usual core work to access GiveWell projects and money. There’s a lot of danger here not only in lower quality or less efficient work, but also mission creep losing focus on our core work. I might write more about this at some point.
Also posted on blog!
Thanks Lauren for this really well thought through and balanced discussion of a really complex topic. This is one of the first times that I’ve seen such a nuanced approach, most articles are banging one side or the other when like you say—its really complicated and I . I have a couple of extra thoughts, which I don’t think add1. I think this situation is so complicated that it is hard to make worldwide generalisations like “Medical immigation is good” or vice versa. Each country’s situation needs to be assessed differently. The Phillipines is a great example which I think is pretty clearly good for everyone, with a few caveats. In Nigeria I’m pretty uncertain as there are a wide range of positives and negatives there. If the new “double the doctors” training initiative came through I would lean towards positive, but otherwise I would lean a little negative (with enormous uncertainty)
2. A few points where calculations could maybe be improved (not the biggest deal)
- You state the cost at $10,000 a year for training doctors, I think its likely to be a lot lower, maybe $5000 to $7000. BUT med school is never 3 years like you’ve estimated, more like 5 or 6 so your end calculation number might be pretty similar!- You’ve left out internal remittances and potential tax benefits to the government in your remittances calculations—these aren’t insignificant as doctors earn decent wages by low income country standards and do benefit the country. This is a tricky counterfactual but our nurses spend about quarter of their income supporting their family, and doctors here would be similar. So if a doctor was earning 1,000 dollars a month, if they spent 20% on their family that would be $2500 a year. I’m not sure how to take this into account exactly under your calculation but I feel like the money local doctors pour into their less well off family members should be taken into account somehow.
And then there’s tax as well. Personally don’t think each tax dollar is worth much in low income countries—but most experts disagree with me.
3. Even though the literature doesn’t talk about it much, I think there are 2 potential harms of immigration that could be really bg but can be hard to quantify (I’ve banged on about this a few times)
- First, often the most experienced and best doctors leave, which opens up leadership vacuums within important institutions. Like if a senior hospital doctor leaves, they aren’t “replacible” immediately. The flow on effects can be way more than just losing a doctor clinically
- Second, the “Japa” effect (Nigeria) where everyone wants to leave the country can sow discontent and produce quite a negative environment. Won’t get into this in detail but have discussed beforeAnyway thanks heaps for the article and again appreciate you bringing in perspectives from all sides without strawmanning!
Maybe they are predicting not for long… ;)
J/k