That might not be what you’re expecting to find in a book that’s also about progress towards an abundant future and making parenting better—but we think it all hangs together and that the connections are part of where readers here might find something interesting. Preventing neonatal deaths is an important way that people have learned from other people. And! We indeed wrote in chapter 7 about why we might need many of us to work together to solve a big problem like a pandemic, decarbonization or, yes, maybe an asteroid.
I really agree, and think that many people who want to do good with their careers should consider a policy master's instead of law school or a PhD. Diane Coffey, Nikhil Srivastav (both of the r.i.c.e. KMC ward https://www.givewell.org/research/grants/rice-kangaroo-mother-care-november-2022), and I all did MPAs. Indeed, that's where Diane and I met!
Thanks for asking! Both of these turn out to be questions at the research frontier.
On 1:
The public-hospital survival advantage in Uttar Pradesh (and a few similar states in north India) is surprising! There’s a literature in development economics that public and private service delivery fails in different ways, because of different incentives. Private providers are paid more when they appear to be doing more, so they often provide unnecessary, or even harmful “treatments.” These interventions tend to do more harm than good for most births. Patients unfortunately don't know this; healthcare is a setting where information asymmetry is severe.
This is an active research area for our team: We’re working on an NIH grant application, and Nathan Franz (a PhD student at UT) is doing great dissertation research on this topic. As a rough answer, private providers have an economic incentive to do things to the baby that they can charge for, so they separate the mom and baby and, say, wash the baby, which might delay breastfeeding or make it cold. Public providers more or less leave the mom and baby alone, which tends to be the best plan for most newborns. I should also note that the data supporting the public-facility survival advantage is about the average baby, not about the low birthweight and premature babies that r.i.c.e.’s program targets (even the big Demographic and Health Survey doesn’t have enough of those babies to have enough statistical power to draw conclusions about that group).
There’s more detail and not every case is the average case, but there’s an interesting implication for our project: If, as the years go on and word gets out, improving care in public facilities attracts more births to happen in public rather than private facilities, that could be a positive externality even for babies who are not small or premature enough to be eligible for this program.
On 2:
Different babies need different things, so there is no one right answer. Hospitals in rich countries are able to provide many more interventions that improve survival chances for the smallest and most preterm babies than hospitals in poor settings, such as Uttar Pradesh. For example, breathing support (ventilators and CPAP) and continuous vital sign monitoring are available in almost all rich country settings. Sometimes these interventions are compatible with KMC and other times they are not. Where they are, doctors and nurses in rich countries are increasingly combining them with KMC. The iKMC trial I talked about occurred in more of a middle-income setting where KMC was combined with continuous vital signs monitoring, but none of the babies were on ventilators, for example. That study found improved outcomes relative to keeping the baby in a radiant warmer with vital sign monitoring.
In settings where staff and machines are scarce, KMC is the standard of care. Given the staff shortages, the cost of machines, and the difficulties of training staff to use those machines, I would argue that it would do more good to expand Kangaroo Care to more babies in poor country settings rather than be able to serve a much smaller number of babies with rich-country style care.
I think the right econ-jargon way to think about this is that they are “complements in production”: The activities that promote skin-to-skin contact make it very natural to also promote breastfeeding. Indeed, that’s one part of why skin-to-skin contact is helpful! It would be odd to have a skin-to-skin promotion program that doesn’t also promote breastfeeding, I mean.
Maybe implicit in your question is the guess that the nurses more or less tell the moms about skin-to-skin contact and then they go along their way and do it. But in fact, the skin-to-skin part is pretty labor intensive too, because it requires keeping the moms present in the hospital and engaged in the effort, instead of giving up and going home. Yes, there’s some troubleshooting (the angle, the KMC wrap, …). But more than that, there’s a lot of cheerleading (“How’s it going?” “You’re doing great!” “Keep it up!”), which is often a big part of good nursing care, and especially here. Part of what the program is doing—by helping the moms have what they need in terms of food, bathroom opportunities, and encouragement—is helping the moms feel good about the long slog of getting these babies up to a safer weight and ready to eat and grow.
I ran this question by a colleague who wrote back: “I think [mere] information campaigns that show parents doing KMC for LBW babies in healthcare settings and at home would be a good idea, and I think that having non-nursing staff (say ward ayas) teaching parents KMC in a hospital setting would be better than not doing so, but I don't think we should expect large effects.
“It takes time for the mothers to learn positioning and wrapping (KMC can be unsafe without these inputs), and the constant checking and temperature measurement and encouragement matter to getting mothers to do enough hours.
“I would say, if you have the option of using trained nursing staff, you should. If you don't, then by all means give people the [mere] information that prolonged skin to skin contact is beneficial for their LBW newborn. But it is not a close second best.”
My sense is that expanding the program at this site (or keeping it alive and well for more years at this site) has increasing returns, because we spread the administrative costs over more babies. In fact, knowing we have the funding runway to keep the program healthy lets us hire higher-quality staff with multi-year commitments. But expanding to another district would have huge fixed costs, even if the marginal cost is identical once it is up and running. We would still have a lot of our learning-by-doing, and we would have the paperwork, software, and protocols that we have developed, but we would fundamentally need some new relationships and a new entrepreneurial leader to captain that ship. We don’t currently have that person, but there is no in-principle reason that they could not be found and hired someday. More broadly, running this program has caused us to realize that cost-effectiveness in EA, philanthropy, and development economics has not paid enough attention to what microeconomic theory knows about fixed, variable, marginal, and average costs all being different. It's on the to-do list to write about that someday.
There are three margins of behavior: The families, the government-salary doctors, and the nurses who are privately hired by the program. The families would counterfactually be bringing most babies home to poor odds. We believe the doctors are working harder and doing more, because the returns to their efforts are improved by the collaboration with the nurses and families. So what about the nurses? Government nurse jobs, for now, remain very hard to get (it's a bad equilibrium where there both are not enough nurses and not enough public facilities to hire them). So these nurses would likely work somewhere in the private sector. Who knows the tiny general equilibrium effect on statewide nurse wages (!) but the quality of healthcare and neonatal survival for babies born in private facilities is worse, on average, than public facilities in this context, so on the margin shifting activity from private to public facilities would be likely to save lives.
If I understand the question, my own view is the opposite: all else equal, saving a neonate is 60 person-months better than saving a five year old. But I personally suspect this isn't a huge practical deal: The uncertainties and variance in cost-effectiveness are plausibly much larger than one-part-in-three.
Hi, everyone! Just to circle back and close the loop: GiveWell has confirmed to us that their legal organization is indeed a public charity, so r.i.c.e. will not have a tipping problem. A big thank you to Jason for figuring that out! We still believe we can put marginal funds to great use, but it is not urgent in this particular "tipping" way. Thanks, everyone!
I'm very glad to see this, and I just want to add that there is a recent burst in the literature that is deepening or expanding the Harsanyi framework. There are a lot of powerful arguments for aggregation and separability, and it turns out that aggregation in one dimension generates aggregation in others. Broome's Weighing Goods is an accessible(ish) place to start.
As you can see, this literature is pretty technical for now. But I am optimistic that in 10 years it will be the case both that the experts much better understand these arguments and that they are more widely known and appreciated.
Hi, everyone! I think the question here is focused on the higher order questions of what GiveWell will recommend (and one level higher) how to ask forecasting questions about it. But, to not answer that, I will say that at r.i.c.e., our fieldwork in India is, in the sense of a majority of our time, effort and staff, mostly spent on lactation consulting and Kangaroo Mother Care for low birthweight babies right now. (One question for the author might be whether a KMC program, which is fundamentally about breastfeeding but also has other mechanisms (keeping the baby warm, keeping the caregiver informed about the baby's status) would could as breastfeeding promotion for this forecast.)
We're working in Uttar Pradesh, which is a context where women's modesty is an important cultural issue. But one challenge we are facing is demand: it's hard for us to get mothers and families more broadly to want to go along with our program. I don't think this should have surprised us so much, but in fact the bindingness of this constraint did surprise us. I would be very excited to hear about practical research, ethnography, or just trial and error anyone is doing about this.
From a prioritization point of view, this sort of approach competes against more resource-intensive neonatal care, such as investing in incubators (which may or may not be plugged in and turned on) which work against establishing breastfeeding by separating the moms and babies. So, another indirect way of doing "breastfeeding promotion" may be to lean against that sort of medicalized policy.
Like so many things for early-life health in poor populations (open defecation, clean cooking fuel use,...), this is an area where the "second stage" biological mechanism seems very well established to me, and what we need is good evidence and strategies for a better "first stage" effect of programs on behavior change.
There’s a nice post right now on the front page about the lifesaving power of immediate skin-to-skin (meaning right after birth, take a look here: https://forum.effectivealtruism.org/posts/bLZj9puhixeYajTJ2/promoting-immediate-skin-to-skin-contact-and-early-1 ) which reminded me that one thing to say about our book is that it also tells some stories from the KMC program that I’ve been involved with in Uttar Pradesh (it's a longer-term intervention, meaning days-to-weeks; I talked and wrote about it here: https://forum.effectivealtruism.org/posts/rwq8WqcQ9hxjxPmud/ask-me-questions-here-about-my-80-000-hours-podcast-on ).
That might not be what you’re expecting to find in a book that’s also about progress towards an abundant future and making parenting better—but we think it all hangs together and that the connections are part of where readers here might find something interesting. Preventing neonatal deaths is an important way that people have learned from other people. And! We indeed wrote in chapter 7 about why we might need many of us to work together to solve a big problem like a pandemic, decarbonization or, yes, maybe an asteroid.
I really agree, and think that many people who want to do good with their careers should consider a policy master's instead of law school or a PhD. Diane Coffey, Nikhil Srivastav (both of the r.i.c.e. KMC ward https://www.givewell.org/research/grants/rice-kangaroo-mother-care-november-2022), and I all did MPAs. Indeed, that's where Diane and I met!
Thanks for asking! Both of these turn out to be questions at the research frontier.
On 1:
The public-hospital survival advantage in Uttar Pradesh (and a few similar states in north India) is surprising! There’s a literature in development economics that public and private service delivery fails in different ways, because of different incentives. Private providers are paid more when they appear to be doing more, so they often provide unnecessary, or even harmful “treatments.” These interventions tend to do more harm than good for most births. Patients unfortunately don't know this; healthcare is a setting where information asymmetry is severe.
This is an active research area for our team: We’re working on an NIH grant application, and Nathan Franz (a PhD student at UT) is doing great dissertation research on this topic. As a rough answer, private providers have an economic incentive to do things to the baby that they can charge for, so they separate the mom and baby and, say, wash the baby, which might delay breastfeeding or make it cold. Public providers more or less leave the mom and baby alone, which tends to be the best plan for most newborns. I should also note that the data supporting the public-facility survival advantage is about the average baby, not about the low birthweight and premature babies that r.i.c.e.’s program targets (even the big Demographic and Health Survey doesn’t have enough of those babies to have enough statistical power to draw conclusions about that group).
There’s more detail and not every case is the average case, but there’s an interesting implication for our project: If, as the years go on and word gets out, improving care in public facilities attracts more births to happen in public rather than private facilities, that could be a positive externality even for babies who are not small or premature enough to be eligible for this program.
On 2:
Different babies need different things, so there is no one right answer. Hospitals in rich countries are able to provide many more interventions that improve survival chances for the smallest and most preterm babies than hospitals in poor settings, such as Uttar Pradesh. For example, breathing support (ventilators and CPAP) and continuous vital sign monitoring are available in almost all rich country settings. Sometimes these interventions are compatible with KMC and other times they are not. Where they are, doctors and nurses in rich countries are increasingly combining them with KMC. The iKMC trial I talked about occurred in more of a middle-income setting where KMC was combined with continuous vital signs monitoring, but none of the babies were on ventilators, for example. That study found improved outcomes relative to keeping the baby in a radiant warmer with vital sign monitoring.
In settings where staff and machines are scarce, KMC is the standard of care. Given the staff shortages, the cost of machines, and the difficulties of training staff to use those machines, I would argue that it would do more good to expand Kangaroo Care to more babies in poor country settings rather than be able to serve a much smaller number of babies with rich-country style care.
I think the right econ-jargon way to think about this is that they are “complements in production”: The activities that promote skin-to-skin contact make it very natural to also promote breastfeeding. Indeed, that’s one part of why skin-to-skin contact is helpful! It would be odd to have a skin-to-skin promotion program that doesn’t also promote breastfeeding, I mean.
Maybe implicit in your question is the guess that the nurses more or less tell the moms about skin-to-skin contact and then they go along their way and do it. But in fact, the skin-to-skin part is pretty labor intensive too, because it requires keeping the moms present in the hospital and engaged in the effort, instead of giving up and going home. Yes, there’s some troubleshooting (the angle, the KMC wrap, …). But more than that, there’s a lot of cheerleading (“How’s it going?” “You’re doing great!” “Keep it up!”), which is often a big part of good nursing care, and especially here. Part of what the program is doing—by helping the moms have what they need in terms of food, bathroom opportunities, and encouragement—is helping the moms feel good about the long slog of getting these babies up to a safer weight and ready to eat and grow.
I ran this question by a colleague who wrote back: “I think [mere] information campaigns that show parents doing KMC for LBW babies in healthcare settings and at home would be a good idea, and I think that having non-nursing staff (say ward ayas) teaching parents KMC in a hospital setting would be better than not doing so, but I don't think we should expect large effects.
“It takes time for the mothers to learn positioning and wrapping (KMC can be unsafe without these inputs), and the constant checking and temperature measurement and encouragement matter to getting mothers to do enough hours.
“I would say, if you have the option of using trained nursing staff, you should. If you don't, then by all means give people the [mere] information that prolonged skin to skin contact is beneficial for their LBW newborn. But it is not a close second best.”
Thanks so much for asking!
Hi, everyone! Just to circle back and close the loop: GiveWell has confirmed to us that their legal organization is indeed a public charity, so r.i.c.e. will not have a tipping problem. A big thank you to Jason for figuring that out! We still believe we can put marginal funds to great use, but it is not urgent in this particular "tipping" way. Thanks, everyone!
Thank you very much! We are excited to learn about this!
I'm very glad to see this, and I just want to add that there is a recent burst in the literature that is deepening or expanding the Harsanyi framework. There are a lot of powerful arguments for aggregation and separability, and it turns out that aggregation in one dimension generates aggregation in others. Broome's Weighing Goods is an accessible(ish) place to start.
Fleurbaey (2009): https://www.sciencedirect.com/science/article/abs/pii/S0165176509002894
McCarthy et al (2020): https://www.sciencedirect.com/science/article/pii/S0304406820300045?via%3Dihub
A paper of mine with Zuber, about risk and variable population together: https://drive.google.com/file/d/1xwxAkZlOeqc4iMeXNhBFipB6bTmJR6UN/view
As you can see, this literature is pretty technical for now. But I am optimistic that in 10 years it will be the case both that the experts much better understand these arguments and that they are more widely known and appreciated.
Johan Gustafsson is also working in this space. This link isn't about Harsanyi-style arguments, but is another nice path up the mountain: https://johanegustafsson.net/papers/utilitarianism-without-moral-aggregation.pdf
Hi, everyone! I think the question here is focused on the higher order questions of what GiveWell will recommend (and one level higher) how to ask forecasting questions about it. But, to not answer that, I will say that at r.i.c.e., our fieldwork in India is, in the sense of a majority of our time, effort and staff, mostly spent on lactation consulting and Kangaroo Mother Care for low birthweight babies right now. (One question for the author might be whether a KMC program, which is fundamentally about breastfeeding but also has other mechanisms (keeping the baby warm, keeping the caregiver informed about the baby's status) would could as breastfeeding promotion for this forecast.)
We're working in Uttar Pradesh, which is a context where women's modesty is an important cultural issue. But one challenge we are facing is demand: it's hard for us to get mothers and families more broadly to want to go along with our program. I don't think this should have surprised us so much, but in fact the bindingness of this constraint did surprise us. I would be very excited to hear about practical research, ethnography, or just trial and error anyone is doing about this.
From a prioritization point of view, this sort of approach competes against more resource-intensive neonatal care, such as investing in incubators (which may or may not be plugged in and turned on) which work against establishing breastfeeding by separating the moms and babies. So, another indirect way of doing "breastfeeding promotion" may be to lean against that sort of medicalized policy.
Like so many things for early-life health in poor populations (open defecation, clean cooking fuel use,...), this is an area where the "second stage" biological mechanism seems very well established to me, and what we need is good evidence and strategies for a better "first stage" effect of programs on behavior change.
Day care for Jeremy the two year old!