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 add

1. 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 before

Anyway thanks heaps for the article and again appreciate you bringing in perspectives from all sides without strawmanning!

I love this take and I think you make a good point but on balance I still think we should keep neglectedness  under "ITN". It's just a framework it ain't clean and perfect. You're right that an issue doesn't have to be neglected to be a potentially high impact a cause area. I like the way you put it here.

"Maybe neglectedness useful as a heuristic for scanning thousands of potential cause areas. But ultimately, it's just a heuristic for tractability'

That's good enough for me though.

I would also say that especially in global development, relative "importance" might become  less "necessary" part of the framework as well. If we can spend small amounts of money solving relatively  smallish issues cost effectively then why not?

You're examples are exceptions too, most of the big EA causes were highly neglected before EA got involved.

When explaining EA to people who haven't heard of it, neglectedness might  be the part which makes the most intuitive sense, and what helps people click. When I explain the outsized impact EA has had on factory farming, or lead elimination, or AI Safety because "those issues didn't have so much attention before", I sometimes see a lightbulb moment.

Thanks Scott interesting questions

1) TO answer this I'm just saying that an artemisin derivative plus another medication (co-artem) will still cure malaria completely almost all of the time, even if it takes longer

I don't have the answer to 2 or 3 exactly and dont' have the time to look into it but you're thnking along the right lines. For every 1,000 children who came into a clinic for malaria, at least 950 would survive with no treatment, but even those that survive are likely to encounter a range of problems such as anemia, low energy, recurrent fevers etc.  Also like you say people would be more prone to dying from other diseases as well after being weakened from malaria, as is well established in the case of diarrheal disease. Malaria actually weakens immunity directly as well. If I recall correctly somewhere between 1 in 10 and 1 in 20 severe malaria cases has co-infection with a bacterial infection.

Hi James and thanks for posting here on the forum, appreciate someone who is obviously a m malaria expert weighing in here with this useful feedback. I will say I was aware of much of the factual information in your feedback, but chose to leave it out for storytelling purposes - for better or worse. 

Overall I was going for a short, simplified narrative article which briefly walked through 5 "acts" in the story of artesunate, while highlighting the incredible discovery story, pointing out that we may have unnecesarily delayed the mass roll out of artemisin treatment and the emerging resistnace issues. I’m writing for a general audience so I didn't focus on scientific details or get into the weeds, while doing my best to not to be misleading . Of course I compromised at times to bring the story out more vividly. I would argue that I make few factual errors, rather I missed out some aspects of the story that could be considered important. I’m interested if you disagree with any of my major points in the article, besides the important scientific information that I omitted?  You write that I "confuse the main issues" and I'm interested in what you think those main issues are?

Thanks to your great feedback I've made a few changes based on your feedback to be more precise - I suspect you won’t be completely satisfied as I still leave out much detail but I hope it helps.

1. I didn’t want to get into the nitty gritty of treatment during the war (simplicity again), but you’re right that for much the war chloroquine was dominant. I’ve changed the wording to to “Chloroquine and quinine took too long to cure malaria and side effects could be rough”. I wonder what you make of the US army’s reports of both apparent chloroquine and Quinine resistance during the war? My main point here was that the Vietnam war stimulated the development of artemesin derivatives.
    
2. I’ve added in those 1996 studies to the timeline thanks!. This only further adds in my mind to demonstrate how slow we were to figure out how much better artemisin derivatives could be than the status quo. I found these 2 studies super interesting as the signal in both of them was leaning towards artemether being better than quinine (although of course not statistically significant). Unfortunately here in Northern Uganda we still use artemether injections for some of our patients here that can’t afford artesunate (aware that it is not as good), as artemether is less than half the price of artesunate. Fortunately in only the last 2 years, artesunate prices have reduced by about 30% which is great so we are using less artemether than ever.
    
3. I chose to leave out the combination treatment part of the story (see below for reasons), but for accuracy’s sake in the final paragraph have added the combination therapy point and changed to “In combination with other medication, artesunate cures over 99%...” 

A little pushback

1. You're right that I didn't get into differentiating between the different artemesin derivatives. Although this is a little imprecise, I don’t think explaining the nature of these different derivatives is a critically important piece of information for the story. Again I’m simplifying for storytelling reasons. 
    
2. I considered describing the combination therapy part of the story, which I agree is important, but decided to leave it out because the injectable artesunate seems to have had a far more important mortality impact than co-artem, and it would have meant telling a slghtly confusing parallel story ;). Feel free to push back here and I agree there is a good argument for adding them to the story - if I wrote a longer article I would have.
   
   - This Rethink Priorities research here estimates that injectable artesunate saved about 1.7 million lives by 2022 while co-artem saved abuot 300,000. This would mean Artesunate is responsible for 85% of the lives saved by artemisin derivatives and co-artem only 15%. This makes sense to me as artesunate provides a large mortality benefit in severe malaria, while other medications if taken properly cure malaria almost as effectively as co-artem. I agree there are many other benefits from co-artem in uncomplicated malaria (side effects, shorter course, faster clearance) and there is a mortality benefit vs alternatives, but far less extreme than for artesunate.
   
   

• Much of the co-artem development story happens in Southeast Asia, which while important accounts for under 5% of malaria deaths.

3) don’t really understand your disagreement with my statement here "adding a 3rd drug to the treatment cocktail – a blunt and expensive instrument but one that could buy us another 10 years." You write "No this is wrong. New drugs currently in development are being developed as "triple" therapy. There are good pharmacological reasons for this around prevention of the emergence of resistance.”

What's "wrong" about my statement here exactly? The Lancet article I quoted discusses the idea of adding a third drug to artemether-lumefantrane as you say, and yes its to avoid the emergence of resistance. It will be expensive to add a third drug and I consider a 3 drug combination a bit of a sledgehammer/blunt tool. Perhaps we largely agree here?

Thanks again for the feedback and I hope to hear more from you here on the forum :).

Thanks Dorothy those are good points.

I'm a huge fan of grassroots organising although its so hard to quantify the benefits of I'm not sure it falls in the realm of what effective altruism can easily get behind. Also grassroots organisation shouldn't need very much money - I've been involved in the past and we didn't need much!

I'm only a fan of leveraging existing orgs if they can really show they are achieving wat they say they are. How do we know current advocates are effective? I can't see a reason reason for me why EA orgs shouldn't be able to start up and work on this over time - I would take a few EA orgs failing at advocacy as some signal that it might not be a super cost effective approach.

I'm skeptical of the idea that there are magical orgs out there doing things that new orgs couldn't replicate at all. Could you suggest some existing orgs that you think are very good that EA could support?

EA does support some too. One example that EA does support with stacks of cash in this space is the Center for Global Development. I've had one terrible interaction with them that lowered my confidence in whether they really are a good faith org and also their general competency, but that doesn't mean they aren't doing impactful stuff.

 

I'm really unimpressed by these estimates. It shocks me how many public health professionals don't understand counterfactuals.

It's really bad that USAID is pulling out but every calculation I've seen from the WHO, UN and others like this wouldn't get you through the first round of GiveWell interviews. 

You have to factor in that other countries and the African governments themselves will likely account for a decent proportion of the shortfall, and that many of the poorest people will buy medications if they have to. The idea that USAID pulling out could cause a 40 percent increase in malaria deaths is beyond ridiculous.

"Why aren’t we publicly shaming AI researchers every day? Are we too unwilling to be negative in our pursuit of reducing the chance of doom? Why are we friendly with Anthropic? Anthropic actively accelerates the frontier, currently holds the best coding model, and explicitly aims to build AGI—yet somehow, EAs rally behind them? I’m sure almost everyone agrees that Anthropic could contribute to existential risk, so why do they get a pass? Do we think their AGI is less likely to kill everyone than that of other companies? If so, is this just another utilitarian calculus that we accept even if some worlds lead to EA engineers causing doom themselves? What is going on..."

Preface I have no skin in this game and no inside knowledge, this is just from reading the forums for a few years plus some chats.

I think you've put this well. Yes I think many people think Anthropic are more likely to not kill us all than other labs. Which is why you'll still see their jobs advertised on on the forum and why big EA people like Holden Karnofsky have joined their team.

There are a lot of people that will agree with you that wee should be fighting and shaming not pandering  (see pause AI), along with a lot of people who won't. There's certainly a (perhaps healthy?) split within the effective altrutism community between those who think we should work technically on the "inside" towards safety and those who think we should just be anti the labs.

Personally I think there's some "sunk cost " fallacy here. After Open Phil pumped all that money into open AI, many EAs joined safety teams of labs and there was a huge push towards getting EAs doing technical safety research. After all that it now might feel very hard to turn around now and be anti the labs.

I also think that perhaps the general demeanor of many EAs is bent towards quiet research, policy and technical work rather than protest and loud public criticism, which pushes against that being a core EA contribution to AI safety too.

I would suggest the role of the US  toppling Democratically elected people like Patrice Lumumba in Congo and in Iran and Guatemala may have caused at least as much suffering as the Uyghur atrocities.

Its hard to imagine anything worse than the "giant leap forward" though.

I've got really mixed feelings here and I don't know which way to swing. I'm still extremely uncertain about how much we can influence aid policy especially amidst the current messy global political situation.

Sure leverage can be high, but the question is how on earth do we get that leverage? What do you suggest? 

I would love to see some great posts on the forum about how we counterfactually could have spent our money or time to prevent this current mess? That might convince me that future work could be valuable too.

To state the obvious Politics is super hard to influence for many reasons including

1) huge money and effort already poured into influencing politics from many angles, so achieving acting in that environment is really difficult.

2) so much unpredictability and change over time.

CE literally started an org which was trying to do something like this, which soon shut down because they didn't feel it was working

https://forum.effectivealtruism.org/posts/emBSDADvCnSwtL2kS/center-for-effective-aid-policy-has-shut-down

I think it's easy to say that leverage is "high" for political action but there still needs to be a meaningful pathway to make that happen. Right now in the wake of trump, AID policy might be a harder needle to shift than ever before. A recently elected left wing government in the UK even just slashed aid by 40 percent - wild stuff. 

There could even be a counter argument that in a world where governments are backing away from international aid and are harder to leverage, increasing EA donations and covering gaps could be more important than a few years ago.

I know EA aligned people put a lot of successful effort into helping USAID funding be more evidence based, which bore great fruits for a while but now it's unfortunately in the dust at least for now

I'm all for political leverage and putting funding into it, but we need concrete fundable ideas different from those we have tried which didn't work already.

Also Making up the shortfall on the ground is a great thing to do, and like your said in no way mutually exclusive from political work.

Although I think there probably are some great AI ideas that could help the world's poorest people, it's not easy to think of these or implement them. Usually the economies of the poorest people involve surprisingly little technology and are based around hand powered agriculture, basic goods and basic services. Internet where it is strong is often surprisingly expensive. 

Y combinator startups aim to make money from the richest people in earth, people's who's economy and lives are tied to technology and the Internet.

So the economic reality and ecosystems are completely different and it's hard for AI tools to penetrate super poor systems, while there's endless ways to capture value in high income countries.

I think there may be some super valuable AI ideas that could change the game for the world's poorest, but it's not obvious or clear yet. 

And where there are good ideas, convincing governments and NGOs to take on new ideas is super difficult. We at OneDay health have made a cool healthcare mapping tool based on AI generated population and road data which has transformed our ability to target our healthcare, and  has potential to help improve healthcare on the margins in multiple ways. NGOs and government showing some interest but besides a small USAID pilot in Pakistan it has been quite hard to get uptake.

https://forum.effectivealtruism.org/posts/GpAngpFmn3HFrBLnt/health-aim-a-mapping-tool-helping-health-providers-reach

I'm a sample size one who lives in a more income context and e been thinking hard about it, but I'm struggling to come up with too maybe potentially useful AI ideas right now.