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.
Understanding the NGO industrial complex, and how aid really works (or doesn't) in Northern Uganda
Global health knowledge
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.
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.
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.